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Journal of Clinical Child and Adolescent Psychology 2005, Vol. 34, No. 3, 380–411 Copyright © 2005 by Lawrence Erlbaum Associates, Inc. Evidence-Based Assessment of Anxiety and Its Disorders in Children and Adolescents Wendy K. Silverman Florida International University Thomas H. Ollendick Virginia Polytechnic Institute and State University We provide an overview of where the field currently stands when it comes to having evidence-based methods and instruments available for use in assessing anxiety and its disorders in children and adolescents. Methods covered include diagnostic interview schedules, rating scales, observations, and self-monitoring forms. We also discuss the main purposes or goals of assessment and indicate which methods and instruments have the most evidence for accomplishing these goals. We also focus on several specific issues that need continued research attention for the field to move forward toward an evidence-based assessment approach. Finally, tentative recommendations are made for conducting an evidence-based assessment for anxiety and its disorders in children and adolescents. Directions for future research also are discussed. The field of child psychology has made significant strides in the past decade in having as part of its armamentarium evidence-based methods and instruments for use in assessing anxiety and its disorders in children and adolescents. Specifically, systematic empirical testing and evaluation of certain assessment methods and instruments have been undertaken. In addition, increased attention has been paid to conducting research that will help in deriving evidence-based guidelines about how to proceed with the assessment of anxiety and its disorders in youths. Examples of evidence-based guidelines or recommendations suggest that the field is beginning to have answers to questions such as the following: If I can give only one rating scale as an anxiety screen, which one should I give? How should I handle discrepant parent–child anxiety assessment data? Can I use a particular instrument to help differentiate between anxiety and other disorders, such as depression? Which measure or set of measures should I include in a treatment outcome study? In this article, our aim is to provide a summary of where the field currently stands when it comes to having evidence-based methods and instruments available for assessing anxiety and its disorders in children and adolescents. This summary serves to highlight the methods and instruments (e.g., interview schedules) that have been most heavily evaluated relative to others (e.g., direct observations), as well as how certain properties of these methods and instruments (e.g., retest reliability) have been more heavily evaluated than others (e.g., clinical significance). The summary also serves to highlight how certain purposes or goals of assessment (e.g., screening) can be better attained with certain methods and instruments (e.g., rating scales) than others (e.g., self-monitoring forms). Our other aim is to summarize where the field stands when it comes to having evidence-based guidelines to questions such as those just mentioned. By so doing, our hope is that the reader will come away with an improved sense of how to proceed in assessing anxiety and its disorders in children and adolescents in a manner that is as evidence based as possible. In addition, our hope is that the article highlights gaps in the current knowledge base regarding evidence-based assessment methods for anxiety and its disorders and stimulates further research to help fill these gaps. Because a special section titled “Assessing Anxiety and Anxiety Disorders in Ethnic Minority Youth” recently appeared in the pages of this journal, we refer the reader directly to this special section (2004, Vol. 33), rather than attempt to summarize the topic here. Similarly, in a special section titled “Laboratory and Performance-Based Measures of Childhood Disorders” (2000, Vol. 29), Vasey and Lonigan (2000) contributed an article on using such measures (e.g., Stroop This study was funded by National Institute of Mental Health Grant R0163997 to Wendy Silverman and R0151308 to Thomas Ollendick. The authors also would like to thank Ximena Franco, Armando Pina, and Yazmin Rey, for their help in the preparation of this article. Requests for reprints should be sent to Wendy K. Silverman, Child and Family Psychosocial Research Center, Child Anxiety and Phobia Program, Department of Psychology, University Park, Florida International University, Miami, FL 33199. E-mail: [email protected] 380 EVIDENCE-BASED ASSESSMENT OF ANXIETY tasks) for assessing child and adolescent anxiety. We refer the reader directly to this article as well. Also, projective methods and related approaches are not covered. Although they are frequently used in practice, their empirical underpinnings have been thoroughly and critically evaluated in past writings (see Lilienfeld, Wood, & Garb, 2000) and have been found to be severely deficient. Ignoring the importance of using evidence-based assessment procedures lead to several limitations, including a failure to advance the assessment technology, a less complete understanding of disorders of youth, and an inability to compare diagnostic and outcome findings across studies (Ollendick, 1999, 2003). We hope this article is helpful in informing the reader about evidence-based assessment procedures for children and adolescents who experience anxiety and its disorders and, even more important, lead the reader to use these procedures in his or her clinical work. We begin with a discussion of definitional and developmental considerations, followed by a brief discussion of a framework for approaching the assessment process and an indication of the main purposes or goals of assessment. We then present the most widely used methods and instruments for use in assessing anxiety and its disorders in children and adolescents and the evidence for each for accomplishing certain goals. The methods covered include diagnostic interview schedules, rating scales, direct observations, and selfmonitoring forms. Definitional Considerations In defining anxiety, we find Barlow’s (2002; Barlow, Allen, & Choate, 2004) recent formulations particularly insightful and useful. According to Barlow, anxiety seems best characterized as a future-oriented emotion, characterized by perceptions of uncontrollability and unpredictability over potentially aversive events and a rapid shift in attention to the focus of potentially dangerous events or one’s own affective response to these events. (p. 104) Along these lines, Barlow noted two main consequences when anxiety becomes a chronic or clinical condition: avoidance and worry. Both avoidance and worry—when they become pervasive, intense, or uncontrollable—represent maladaptive ways that individuals attempt to cope with their aversive anxious states. Barlow further discussed the evidence showing that as individuals are faced with their anxiety-eliciting situations, elevated physiological arousal occurs. As such, Barlow endorsed the three-response system to anxiety first articulated by Lang (1968). Our definition thus far has centered on anxiety and on how clinical manifestations of anxiety are characterized primarily by avoidance, worry, and physiological arousal; where then does “fear” fit in? Again, we find Barlow’s (2002) formulations helpful. Barlow viewed the clinical manifestation of fear as “panic” or “the unadulterated, ancient, possibly innate alarm system” (p. 104). He noted the striking similarities between a specific fear response and a panic attack, namely, both are characterized by strong behavioral urges to avoid or escape as well as similar underlying neurobiological and neurophysiological processes. At a response level, it can be seen that anxiety and fear are quite similar: They both are characterized by cognitive, behavioral, and physiological indexes. Anxiety and fear typically have three common referents in the clinical literature, as symptoms, syndromes or disorders, and nosological entities (Beck, 1967). At the symptom level, these terms usually refer to the layperson’s denotation (e.g., anxiety is a subjective feeling of tension; fear is a sense of dread or impending doom). As a syndrome or disorder, anxiety and fear refer to a group of symptoms that cluster together (discussed further later). The symptoms that cluster together to comprise anxiety or fear map onto Lang’s (1968) triple response conceptualization, as noted earlier, in which the response is displayed across (a) the behavior or motor response system (e.g., behavioral avoidance), (b) the somatic or physiological response system (e.g., increased heart rate), and (c) the cognitive or verbal response system (e.g., reports of danger or apprehension). Finally, as a nosological entity, anxiety and fear usually refer not only to syndromal specificity but also to a set of symptoms that should display a certain time-course, prognosis, and probable treatment response (Kazdin, 1990). In this article, we use the term anxiety and its disorders because we oftentimes are referring to anxiety and fear as symptoms as well as syndromes or disorders and nosological entities, with no distinctions made between the latter two referents and, unless otherwise indicated, no distinction made between fear and anxiety at the response level. There are methods and instruments available for assessing each of the three response systems of anxiety and fear at the symptom level as well as at the syndrome or disorder and nosological entity level. Although a tripartite assessment approach to anxiety has long been espoused (Rachman & Hodgson, 1974), it is unclear whether the multiple measures across the three response systems offer incrementally meaningful information to assessment (Johnston & Murray, 2003) or treatment planning (Davis & Ollendick, 2005) relative to the assessment of a single response system in isolation. In addition, as Davis and Ollendick noted, concordance among the three systems is oftentimes wanting, and most researchers have not shown that efficacious treatments address and reduce the three re381 SILVERMAN AND OLLENDICK sponse modes even when they are present. Still, at this time, it appears best to attempt to assess each of these response modes whenever possible and until more firm findings are made available to us. It continues to be more common in research and clinic settings to assess the three response systems using self-reports. For example, although exceptions exist (e.g., Beidel, Turner, & Morris, 1999), it has been more common to ask a child to rate how much “My heart beats fast when I feel anxious” or “I worry about making mistakes” and to evaluate the psychometrics of such reports than to use heart-rate monitors or laboratory-based measures to elicit various cognitive processes. Because research support for the direct clinical utility of psychophysiological and laboratory-based measures is less clear and because both require a level of technology and expertise that is quite specialized, they are not summarized in this article (see King, 1994, and, as noted earlier, Vasey & Lonigan, 2000, for summaries). Developmental Considerations Much of the anxiety and fear experienced by children and adolescents develops at particular junctures in development based on normative age-related experiences (e.g., anxiety about separation as children begin prekindergarten or kindergarten, anxiety about social evaluation as adolescents become more involved with peers or attempt romantic attachments, fear following an embarrassing event at school or in the community). When such normative experiences lead children and adolescents to avoid these experiences (e.g., school, parties) or to have uncontrollable worry and heightened physiological arousal about them, it is likely that the anxiety has become a nonnormative or “clinical” problem. In addition to the importance of assessing clinical child and adolescent anxiety problems in a manner that is consistent with the evidence base, it is equally important that the assessment procedures be developmentally sensitive (Ollendick & King, 1991; Silverman & Ollendick, 1999). Probably the most distinguishing characteristic of young people is change. Change has implications for the selection of specific assessment strategies, in their value in understanding the different anxiety disorders, and in evaluating treatment outcome. To illustrate briefly, diagnostic interviews are difficult to conduct, and self-reports may be less reliable with young anxious children, whereas self-monitoring and behavioral observation may be more reactive with older anxious children and adolescents (Ollendick, Grills, & King, 2001; Ollendick & Vasey, 1999). Unfortunately, though, how development should precisely dictate the assessment process with anxious children has not been systematically studied. In addition, as will become apparent, many anxiety assessment methods and instruments for children have 382 been extended downward from those used with adults with insufficient attention paid to whether adaptations or changes are needed. Furthermore, in most instances, the underlying assumptions about these methods and the underlying constructs they are said to measure are the same. Further, measures designed specifically for children may be problematic, inasmuch as a 4-yearold’s world and his or her interpretations of it may be quite different from that of an 8-, 12-, or 16-year-old’s (Ollendick et al., 2001; Ollendick & Vasey, 1999; Silverman & Ollendick, 1999). Kendall (1984) referred to the practice of treating all children alike as the “developmental uniformity myth.” Just as children differ from adults, so too do young children differ from older ones, and older ones, in turn, differ from adolescents. Moreover, the expectations we have for children and adolescents vary with age, as do the norms associated with certain behaviors. Several studies have described “normal age trends” associated with certain behavioral problems (cf. Edelbrock, 1984). In the context of child and adolescent fears, the interaction between emerging cognitive abilities and specific situational events are believed to occasion the presence and intensity of specific fears and phobias that have been shown to occur with regularity during the course of development (Muris, Merckelbach, Mayer, & Prins, 2000; Ollendick, King, & Frary, 1989). Awareness of developmental trends such as these can serve as a guide in the selection of meaningful target fear and anxious behaviors and the interpretation of their significance for the growing child. Ollendick and Hersen (1984) earlier suggested that the developmental point of view can best be incorporated into our research and clinical practice by invoking “normative-developmental” principles. Implicit in this approach is the notion that current behavior can be viewed as a function of the context in which it occurs, including consideration of antecedent and consequent events. That is, whereas the developmental principle calls attention to the importance of accounting for quantitative and qualitative changes that occur with development, the normative principle points to the need for evaluation of youths’ behaviors with respect to appropriate reference groups. Most generally, the appropriate reference group involves youths of the same age. Obviously, age is a crude index of developmental level, and there are additional limits to the use of norms, as discussed later, yet age can yield important comparative information along a number of dimensions, including the youth’s emotional, cognitive, behavioral, and social functioning. Bongers, Koot, van der Ende, and Verhulst (2003) conducted an excellent example of the type of research that we are advocating for here, in that normative information on common childhood problems across age ranges was gathered. Ideally, normative information related to gender, socioeconomic status, race, culture, and nationality also would be EVIDENCE-BASED ASSESSMENT OF ANXIETY gathered. In this way we can be assured that the comparison group is truly a representative one. Given base rates for normal changes in the reference group, we could then identify those behaviors in the targeted child and his or her family that are outside the normal range. The importance of contextual aspects of behavior must also be noted, such that behaviors viewed as problematic in one setting (e.g., school) may not be viewed as such in a different setting (e.g., community). In sum, incorporating developmental theory into child and adolescent evidence-based assessment is of considerable importance. From our standpoint, developmentally informed assessment is made possible by (a) attention to cognitive and socioemotional developmental processes in the selection of assessment measures, (b) use of normative guidelines in interpreting adaptive and maladaptive behavioral outcomes, (c) examination of age differences in the patterning of behaviors and syndromes, and (d) awareness of the stability and change in behavior over time. These developmental features are important not only for our initial assessment practices with youths and their families but also for outcome assessment. As noted by Weisz and Weersing (1999), clinical child and adolescent psychologists are, in a sense, “chasing the normal developmental curve” (p. 460) when they undertake outcome assessment with children and adolescents. In most instances, the goal of treatment is to “return children to healthy developmental pathways” (Shirk, 1999, p. 68). 1996, 1997) is to be guided by what works with the particular problem that we are trying to solve or the particular goal we are trying to accomplish. We resort on this pragmatic criterion because it helps us to accomplish our ultimate goal, namely, to help the children and families with whom we work. Thus, in the subsequent sections we describe the most widely used methods and instruments for assessing anxiety and its disorders in children and adolescents, with an eye on highlighting which of them works best for in terms of satisfying particular purposes or attaining certain goals. We also acknowledge the limits of these methods and instruments in accomplishing these purposes or goals. With respect to the purposes or goals of assessment, we draw on B. J. Jensen and Haynes (1986), as we believe the purposes or goals they delineated continue to be highly relevant in working with clinical child and adolescent populations; these are (a) screening, (b) diagnosing, (c) identifying and quantifying symptoms and behaviors, (d) identifying and quantifying controlling variables or assessing contextual variables, and (e) evaluating and monitoring treatment outcome and mediators or moderators. Assessment Methods and Instruments for Anxiety and Its Disorders in Youth Semistructured and Structured Diagnostic Interview Schedules A Framework for Approaching the Assessment Process and the Purposes and Goals of Assessment Silverman and Kurtines (1996, 1997) noted the utility of having a pragmatic framework or attitude when approaching the assessment process. A pragmatic framework or attitude dictates that researchers and clinicians alike suspend judgment with respect to what will work and what will not work. That is, researchers and clinicians ought not to simply “fall back” on their favorite assessment method, whatever it happens to be (e.g., projectives, clinical interviews). It may be the eventual choice (and it may work fine), but it is not a good idea to resort to it without considering the available alternatives. A pragmatic attitude further suggests that in deciding on what assessment method to use, the method chosen should be the one that is most useful in a particular setting. Part of what it means to be useful is that the method is clinically feasible in a particular setting. It also means choosing the method that ultimately works best in accomplishing the specific goal. We recognize that best is a normative concept that derives its meaning and significance from the context in which it is used. The criterion that we advocate and recommend in this article and elsewhere (Silverman & Kurtines, The clinical interview is the most prominent method of assessment in clinical child and adolescent psychology (Ollendick & Hersen, 1993; Silverman, 1994). Despite the prominence of the clinical interview, it produces considerable error or variance attributed to interviewers, usage in diagnostic criteria, or both (Silverman, 1994). In addition, it can be daunting to fully ascertain the wide range of problems that a youth may experience in light of the high rates of comorbid (cooccurring) disorders in youth. Partly in response to the limits in using unstructured clinical interviews, semistructured and structured diagnostic interview schedules were developed for use with youths, including those with anxiety problems. Their most frequent use has been in the diagnosis process, including the identification and quantification of youths’ symptoms and behaviors, by using the module of an interview schedule as a “mini” subscale. They also have been frequently used in the treatment evaluation research process by determining diagnostic recovery rates of the sample from pre- to posttreatment. So, for example, of 100% of the youths who meet diagnostic criteria at pretreatment, at posttreatment perhaps 80% are recovered or are no longer meeting diagnostic criteria. We discuss this in more detail later. 383 SILVERMAN AND OLLENDICK Interview schedules have been developed to cover the different types of anxiety disorders specified in the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM–IV]; American Psychiatric Association, 1994). Table 1 summarizes the key clinical features of the most prevalent anxiety disorders displayed by children and adolescents that are covered in interview schedules. The table highlights that most anxiety disorders share similar processes. For example, most are characterized by apprehension of situations or objects as well as anxiety-reducing actions such as avoidance (Barlow, 2002; Silverman & Kurtines, 1996). How they differ is in terms of the content or the focus of apprehension (e.g., worries about embarrassment in social phobia [SOP], worry about harm befalling parents in separation anxiety disorder [SAD]; Barlow, 2000; Silverman & Kurtines, 1996). This difference among the anxiety disorders constitutes the key reason why we believe using structured or semistructured interview schedules is necessary from an evidence-based perspective. Namely, the current treatment approach that has the strongest and most consistent research support for reducing any anxiety disorder in young people is the cognitive behavioral treatments (CBT), which involve exposure-based exercises both in session and out of session (situational, imaginal, and interoceptive; Ollendick & King, 1998; Silverman & Berman, 2001). Indeed, Westen, Novotny, and Thompson-Brenner (2004), in their critical re- view of the “empirical status of empirically supported psychotherapies” (p. 631), similarly acknowledged that the phobic and anxiety disorders “are the disorders that and treatments that have generated the clearest empirical support using RCT [randomized clinical trial] methodology: exposure-based treatments” (p. 658). Although Westen et al. were not referring directly to the child and adolescent treatment research literature when they made this statement, the fact is that this statement is true whether one is working with child, adolescent, or adult populations. Hence, although Westen et al. and others (e.g., Goldfried & Wolfe, 1998) have criticized the strong linkage between diagnosis and treatments in the evidenced-based treatment movement, even among these critics, this concern appears minimized in the context of phobia and anxiety treatment because of the strong research evidence showing support for exposure CBT approaches. Consequently, if one wishes to use the treatment that possesses the most research evidence, it is important to first have confidence (i.e., have reliable and valid information) that the youth or groups of youths with whom one is working are in fact suffering primarily from clinical levels of anxiety, rather than some other clinical disorder, such as attention deficit hyperactivity disorder (ADHD). Second, it is important to have confidence about the specific type(s) of anxiety disorder from which the youth is suffering so that the appropriate exposure tasks can be assigned in and out Table 1. DSM–IV Anxiety Disorders Disorder Separation Anxiety Disorder Specific Phobia Social Phobia Generalized Anxiety Disorder Panic Disorder Posttraumatic Stress Disorder Obsessive–Compulsive Disorder Clinical Features Excessive and developmentally inappropriate anxiety concerning separation from home or attachment figures that begins prior to 18 years old, has been present for at least 4 weeks, and causes clinically significant distress or impairment in important areas of functioning (e.g., social, academic). Marked, excessive, and persistent fear in either presence or anticipation of a circumscribed object or event that is developmentally inappropriate, leads to avoidance or attempts at avoidance of object or event, not due to a recent stressor, present for at least 6 months, and causes clinically significant distress or impairment. Marked and persistent fear circumscribed (e.g., school) or pervasive (e.g., school, family, and friends) of situations in which there is likelihood of social evaluation for at least 6 months leads to avoidance or attempts at avoidance of situation and causes clinically significant distress or impairment. Excessive anxiety and worry that is difficult to control, not focused on a specific situation or object, unrelated to a recent stressor, occurs more days than not, at least one physical symptom (e.g., restlessness, stomach, and muscle aches), present for at least 6 months, and causes clinically significant distress or impairment. Sudden occurrence of a cluster of symptoms that peaks within 10 min (e.g., palpitations, sweating, trembling, feelings of shortness of breath, chest pain, nausea, dizziness). Reoccurs unexpectedly, associated with at least 1 month of chronic worry or fear about future attacks and consequences regarding attacks, and leads to avoidance or attempts at avoidance. Can occur either independently or with agoraphobia. Exposure to a traumatic event leads to persistent reexperiencing (e.g., intrusive thoughts or images), persistent avoidance of situations or persons associated with event or lack of responsiveness (e. g., avoid thoughts, feelings, conversations associated with or a reminder of event), and increased arousal (e. g., hypervigilance, sleep disturbance). Present for at least 1 month and causes clinically significant distress or impairment. Obsessive thoughts, impulses, or images, compulsions, or both that lead to marked distress, last over 1 hr a day, and causes clinically significant distress or impairment. Attempts are made to ignore obsessions; relieve distress by performing compulsions. Note: DSM–IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed., American Psychiatric Association, 1994). 384 EVIDENCE-BASED ASSESSMENT OF ANXIETY disorder was identified in sufficient numbers in the study’s samples, usually at least five cases. That is why some disorders have reliability information and others do not. This raises an important issue about base rates that is worthy of a few additional comments (see Johnston & Murray, 2003, for further discussion). As Table 2 shows, current knowledge about the reliability of diagnoses is limited to those anxiety disorder subtypes that possess relatively high base rates in youth. Consequently, little is known about the diagnostic reliability using interview schedules of the disorder subtypes with relatively low base rates in youth (i.e., panic disorder [PD], agoraphobia, posttraumatic stress disorder, and obsessive–compulsive disorder). In addition, most of the diagnostic reliability research work has been conducted in child anxiety disorder specialty clinics (e.g., Rapee, Barrett, Dadds, & Evans, 1994; Silverman, Saavedra, & Pina, 2001) in which the base rates of the anxiety disorders are undoubtedly higher than in other clinics or settings. Consequently, it is important that additional research be conducted on the reliability of anxiety disorder diagnoses in settings in which base rates of specific anxiety disorders are lower and in which other childhood disorders are observed (e.g., Grills & Ollendick, 2003). From an evidencebased assessment perspective, researchers and clinicians who use structured or semistructured interviews should not assume that simply using these more datastructured interviewing procedures guarantees that all anxiety diagnoses obtained are reliable. They may or may not be. More research is needed before we can say for sure. of the treatment sessions (e.g., expose the child to social evaluative situations if the child has social anxiety disorder and to separation situations if the child has SAD). Nevertheless, as Nelson-Gray (2003) astutely pointed out, a full empirical test of the preceding statement has yet to be undertaken. That is, it has not been empirically tested whether children who have had their diagnoses assigned with a diagnostic interview schedule and receive CBT versus a group of children who have not been given a diagnostic interview schedule and receive CBT experience different outcomes. Put another way, the “treatment utility” of conducting interview schedules has not yet been demonstrated, so all the field really has now is “pseudotreatment utility” (Nelson-Gray, 2003). Although a demonstration test of treatment utility has not been done, it is difficult for us to understand how CBT could be exactly (or correctly, or appropriately) implemented and exposure tasks assigned within a CBT protocol unless a clinician knows that the youth has an anxiety disorder, in the first place, and what type of disorder it is, in the second place. It seems to us that starting CBT without this information would be like starting a fishing trip without bringing the fishing rod and bait. One may eventually catch a fish, but it would seem a lot easier with a rod and some bait. Table 2 presents a brief description of the most widely used semistructured and structured youth diagnostic interview schedules that contain sections for diagnosing anxiety disorders as well as the reliability coefficients that were obtained when the schedules were used to diagnose some of the disorders. Studies only calculate and report reliability information if a specific Table 2. Structured and Semistructured Interview Schedules for Diagnosing DSM–IV Anxiety Disorders in Youth Diagnostic Interview Schedule Ages (Years) Versions Structured or Semistructured Reliability of Anxiety Diagnoses (κ coefficients) Anxiety Disorders Interview Schedule for DSM–IV: Child and Parent Versions (Silverman & Albano, 1996; Silverman, Saavedra, & Pina, 2001) 6 to 18 C/P SS Child: SAD = .78; SOP = .71; SP = .80; GAD = .63. Parent: SAD = .88; SOP = .86; SP = .65; GAD = .72. Combined: SAD = .84; SOP = .92; SP = .81; GAD = .80. Child and Adolescent Psychiatric Assessment (Angold & Costello, 2000) 9 to 13 C S Child: OAD = .74; GAD = .79. Diagnostic Interview for Children and Adolescents (Herjanic & Reich, 1982; Reich, 2000) 6 to 17 C/P/A SS Child: OAD = .55; SAD = .60; SP = .65. Adolescent: OAD = .72; SAD = .75 (past) NIMH Diagnostic Interview Schedule for Children Version IV (Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000) 9 to 17 C/P S Child: SP = .68; SOP = .25; SAD = .46. Parent: SP = .96; SOP = .54; SAD = .58; GAD = .65. Combined: SP = .86; SOP = .48; SAD = .51; GAD = .58. Schedule for Affective Disorders and Schizophrenia for School-Age Children (Ambrosini, 2000) 6 to 18 C/P SS Combined: OAD = .78; SP = .80. Note: DSM–IV= Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994); C = child; P = parent; A = adolescent; S = structured; SS = semistructured. SAD = separation anxiety disorder; SOP = social phobia; SP = specific phobia; GAD = generalized anxiety disorder; OAD = overanxious disorder; NIMH = National Institute of Mental Health. 385 SILVERMAN AND OLLENDICK Further, different assessment strategies would likely be needed as a function of the disorder’s base rate in that particular setting (Johnston & Murray, 2003). For example, given the relatively high base rates for SOP diagnoses in most clinic settings, particularly in anxiety disorder specialty clinics, it is reasonable to proceed with a full diagnostic interview when trying to identify youth with this disorder. However, for selective mutism—a possible variant of SOP with a low base rate—it would seem more cost and time efficient to use a multistage sampling design (Kendall, Cantwell, & Kazdin, 1989) in which “screener” questions might be administered first. This would be followed by a fuller diagnostic interview for those youths who are “caught in the net” of the screen (Costello & Angold, 1988). Due to the absence of specific base rate information about each anxiety disorder in diverse clinical, school, and community settings, details of how this type of multistage sampling strategies might be conducted across settings and across the different subtypes of disorders (e.g., which screen for which disorder in which setting?) remain sketchy. Table 2 also summarizes studies in which evaluating reliability was the primary objective. Thus, although it is fairly standard practice for research articles to report diagnostic reliability, the table does not summarize the reliability data that were reported in every study in which an interview schedule was used. In addition, although all the schedules listed in Table 2 contain sections on the DSM–IV anxiety disorders, the Anxiety Disorders Interview Schedule for Children for DSM–IV: Child and Parent Versions (ADIS: C/P; Silverman & Albano, 1996; Silverman et al., 2001), similar to the adult version, the Anxiety Disorders Interview Schedule for DSM–IV (Brown, Di Nardo, & Barlow, 1994) is more detailed in its coverage. Probably for this reason, the ADIS: C/P and its previous versions (3rd ed. and 3rd ed., rev.; Silverman, 1991) have been used most frequently in the youth anxiety disorders research literature, including the randomized clinical trials (see Table 7 and Silverman & Berman, 2001). The ADIS: C/P contains not only questions that allow for diagnoses of anxiety disorders but also contains questions that allow interviewers to assign ratings from 0 to 8 on the youths’ fear and avoidance of diverse situations in each of the diagnostic categories in which fear or avoidance occurs (e.g., SOP, specific phobia), allowing for an identification and quantification of symptoms. It also contains questions that allow for obtaining information about the history of the problem and situational and cognitive factors influencing anxiety, as well as sections that cover the most prevalent conditions of childhood and adolescence (e.g., ADHD, conduct disorder, depressive disorder) and screening questions for most others (e.g., eating disorders, enuresis). 386 Given the importance of knowing which anxiety disorder should be targeted in an exposure-based CBT, the ADIS: C/P further assists with this by providing clinician severity rating scales. Based on the information obtained during the course of the interview, interviewers assign the degree of distress and interference in functioning associated with each disorder, ranging from 0 (none) to 8 (very severely disturbing/impairing). Similar to the adult ADIS, clinician severity ratings of 4 (definitely disturbing/impairing) or higher are considered “clinical” diagnoses, and those of less than 4 are viewed as “subclinical” or subthreshold. Principal status, and the disorder that would then be targeted using CBT, would be the disorder that is determined to be relatively most severe and interfering. Although the ADIS: C/P has been used most for assisting in the subsequent assignment of youths to an evidence-based CBT program in the way just described (i.e., target the disorder with the highest severity rating scores), as discussed further later, research is needed on exactly what the scores on the clinician severity rating scale truly mean in terms of real-world impairment. Studies have confirmed, however, the reliability and validity of diagnoses using the ADIS: C/P, with several studies confirming its interrater (Grills & Ollendick, 2003; Rapee et al., 1994; Silverman & Nelles, 1988) and test–retest reliability for specific diagnoses (Silverman & Eisen, 1992) as well as symptom patterns (Silverman & Rabian, 1995). These studies were all conducted in university-based research clinics. In a recent study in which the characteristics of youths with anxiety disorders at research-based clinics versus community-based clinics were compared, reliability of the diagnoses was not reported in the community clinic using the Diagnostic Interview Schedule for Children (Southam-Gerow, Weisz, & Kendall, 2003). The lack of data on the reliability and validity of anxiety diagnoses when diagnoses are obtained in community clinics likely reflects, in part, the general difficulties in gathering “effectiveness” data (assessment or treatment) in nonresearch settings (e.g., clinicians are burdened with large case loads, reduced incentives for gathering data in applied settings, and so on; Weisz, 2000). Gathering such data is important to move the field forward with respect to having interviewing assessment procedures that are fully evidence based. With regard to validity, in Wood, Piacentini, Bergman, McCracken, and Barrios (2002), the concurrent validity of ADIS: C/P diagnoses of SOP, SAD, generalized anxiety disorder (GAD), and PD was examined in children and adolescents referred to an outpatient anxiety disorders clinic (N = 186; ages 8 to 17 years). Youths and parents were administered the ADIS interviews as well as the Multidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan, Stallings, & Conners, 1997). There was strong corre- EVIDENCE-BASED ASSESSMENT OF ANXIETY spondence between the ADIS: C/P diagnoses and empirically derived MASC factor scores corresponding to these disorders, with the exception of GAD. In addition, there was an absence of convergent or presence of divergent validity as would be predicted (e.g., MASC social anxiety factor scores but no other factor scores were significantly elevated for children meeting DSM– IV SOP on the ADIS: C/P). As noted, the child and parent ADIS interviews have been used in almost all the randomized clinical trials that have been conducted to evaluate the efficacy of CBT to reduce anxiety disorders in treated youths (see Table 7). In all of these studies, significant improvements in diagnostic recovery rates were observed in the majority of the treated youths at posttreatment and follow-up. In sum, relative to the other interview schedules listed in Table 2, the ADIS: C/P has been studied the most in the youth anxiety disorders treatment research area and has the strongest evidence when it comes to providing reliable and valid diagnoses and sensitivity to clinical change in treatment outcome research. In addition, as noted, it is our view that interview schedules are important from a treatment utility perspective, though this view needs to be further established empirically. Rating Scales Table 3 presents the most widely used youth selfrating scales that have been used for assessing anxiety and related symptoms such as fear. The table does not emphasize scales designed to assess anxiety disorders that have lower base rates in youths, such as posttraumatic stress disorder. See the recent review by Ohan, Myers, and Collett (2002), for a summary of scales assessing trauma and its effects. Table 4 presents the most widely used parent and teacher rating scales, and Table 5 presents recently developed clinician rating scales. Table 6 presents a sampling of rating scales that can be used to assess contextual aspects of anxiety and its disorders in youth. Generally speaking, the rating scales listed have been well tested in terms of internal consistency and test–retest reliability and thereby possess sufficient and adequate evidence when it comes to the criterion of reliability. Consequently, the reliability information of the rating scales is summarized in the tables. With regard to validity, most of the rating scales have research evidence when it comes to concurrent validity in that they show positive convergence with related constructs and divergent validity in that they do not converge with unrelated constructs. This is particularly true when it comes to the scales’ total scores, with findings regarding particular subscales of the rating scale varying. Due to space constraints, it is not possible to summarize all of the studies that have been conducted to establish each scale’s concurrent and discriminant validity. Later in the article we summarize this line of research with the most widely used and widely researched youth self-rating anxiety scale, the Revised Children’ Manifest Anxiety Scale (RCMAS). Interestingly, however, the psychometric properties of most of these scales, including the RCMAS, have been empirically established mainly for community samples of youths. There are some notable exceptions, such as the Pediatric Anxiety Rating Scale (PARS), described later. With this scale, for example, the data reported were based only on a clinically anxious sample (Research Units on Pediatric Psychopharmacology Anxiety Study Group, 2002). This too has limits with regard to generalizability of the findings to other clinical samples or community samples. Returning to the purposes and goals of assessment, all of the rating scales listed in the tables have been used in the research literature for identifying and quantifying symptoms or behaviors. Many of them also have been used for evaluating treatment outcome (see Table 7). With regard to screening, only a small number of the rating scales have begun to be evaluated for this purpose (e.g., the RCMAS, MASC, Social Anxiety Scale for Children–Revised [SASC–R], and Social Phobia and Anxiety Inventory for Children [SPAI–C]). Finally, the scales listed on the tables, particularly Table 6, have the potential to be used for identifying and quantifying maintaining or controlling variables of anxiety and evaluating mediators or moderators in treatment outcome research, though they have not been used as much for this purpose. A few additional comments now follow about using rating scales for each of these purposes, except for screening, which is discussed in a separate section of the article. The use of any of these rating scales to quantify a youth’s level of anxiety is accomplished by administering the scale to the informant and obtaining a score, which serves to quantify the youth’s standing on the anxiety construct in terms of amount, degree, or magnitude. The term metric refers to the range of numbers that the observed measures take on when describing youths’ standings on the construct of interest and the way that those numbers map onto the underlying dimension (Blanton & Jaccard, in press). As Blanton and Jaccard pointed out, however, metrics in psychological research often are arbitrary. This is the case with all the rating scales presented in the tables. Let’s illustrate with the most widely used scale, the RCMAS. When the RCMAS is administered to youths, a Total Anxiety score is obtained based on summing 28 of the scale’s 37 items (with the other 9 items comprising the Lie scale). If a youth obtains a score of 13, this number and where it falls on the metric does not give us a “real-life” picture of how anxious the youth is. Indeed, that same score can occur with youths who meet DSM–IV diagnoses of anxiety as well as youths who also meet other diagnoses (e.g., Perrin & Last, 1992). To render the score less arbitrary and thereby more evidence based, it 387 388 Table 3. Youth Self Rating Scales for Assessing Anxiety and Its Disorders Instrument Ages (Years) Brief Description Affect and Arousal Scale (Chorpita, Daleiden, Moffitt, Yim, & Umemoto, 2000; Daleiden, Chorpita, & Lu, 2000) 8 to 19 Anxiety Control Questionnaire for Children (Weems, Silverman, Rapee, & Pina, 2003) 9 to 17 Children’s Automatic Thoughts Scale (Schniering & Rapee, 2002) 7 to 16 Child Anxiety Sensitivity Index (Silverman, Fleisig, Rabian, & Peterson, 1991) 6 to 17 Fear Survey Schedule for Children–Revised (Ollendick, 1983) 7 to 18 Multidimensional Anxiety Scale for Children (March, Parker, Sullivan, Stallings, & Conners, 1997; March, Sullivan, & James, 1999) 8 to 19 Negative Affect Self-Statement Questionnaire (Ronan, Kendall, & Rowe, 1994) 7 to 15 Penn State Worry Questionnaire for Children (Chorpita, Tracey, Brown, Collica, & Barlow, 1997) 6 to 18 Physiological Hyperarousal Scale for Children (Laurent, Catanzaro, & Joiner, 2004) 12 to 17 27 items. Assesses affective dimensions related to anxiety and depression. Yields three subscales: NA (Negative Affect), PA (Positive Affect), and PH (Physiological Hyperarousal). Respondents rate how true each item is with respect to their usual feelings. 30 items (14-item external subscale, 16-item internal reactions subscale). Assesses perceived lack of control over anxiety-related external threats and negative emotional and bodily reactions associated with anxiety. Respondents rate their agreement with each question (i.e., “I can take charge and control my feelings”). 40 items. Assesses automatic thoughts about physical threat, personal failure, and hostility. Respondents rate the frequency with which they have experienced each thought over the past week. 18 items. Assesses aversiveness of experiencing anxiety symptoms. Yields four subscales: Disease Concerns, Unsteady Concerns, Mental Incapacitation Concerns, and Social Concerns. Respondents rate how aversively they view anxiety symptoms. 80 items. Assesses subjective levels of fear. Yields a total score and five subscales: Fear of Failure and Criticism, Fear of the Unknown, Fear of Danger and Death, Medical Fears, and Small Animals. Respondents rate amount of fear elicited by each object or situation listed. 39 items. Assesses anxiety in four domains: Physical Symptoms, Social Anxiety, Harm Avoidance, and Separation/Panic. Respondents rate how true each item is for them. 11–31 Items (depending on age group). Assesses self-statements related to negative affect (i.e., “I was afraid I would make a fool of myself”). Anxious self-statements are different for 7- to 10-year-olds. Respondents rate the frequency with which they experience a range of automatic thoughts. 14 items. Assesses frequency and controllability of worry. Respondents rate how much they agree with each statement (i.e. “Many things make me worry”). 18 items. Assesses physiological hyperarousal, defined as bodily manifestations of autonomic arousal. Respondents rate how often they have experienced symptoms (i.e., “sweaty hands/palms”) during the past 2 weeks. Reliability Internal consistency: NA subscale = .80; PA subscale = .77; PH subscale = .81. Test–retest reliability: NA subscale = .68; PA subscale = .68; PH subscale = .72. Internal consistency: External subscale = .86; Internal subscale = .89; Total scale = .93. Test–retest reliability: Not reported. Internal consistency: Total scale = .94. Test–retest reliability: Total scale = .79. Internal consistency: Total scale = .87. Test–retest reliability: Total scale = .76. Internal consistency: Total scale ranges from .92 to .95. Test–retest reliability: Total scale = .82. Internal consistency: Total scale and subscales range from .74 to .90. Test–retest reliability: Total scale and subscales range from .34 to .93. Internal consistency: Total scale ranges from .89 to .96. Test–retest reliability: Total scale ranges from .78 to .96. Internal consistency: Total scale = .89. Test–retest reliability: Total scale = .92. Internal consistency: Total scale = .87. Test–retest reliability: Not reported. Positive and Negative Affect Schedule for Children (Laurent et al., 1999) 8 to 14 Revised Child Anxiety and Depression Scales (Chorpita, Yim, Moffitt, Umemoto, & Francis, 2000) 6 to 19 Revised Children’s Manifest Anxiety Scale (Reynolds & Richmond, 1985) 6 to 19 Screen for Child Anxiety Related Emotional Disorders (Birmaher et al., 1999; Birmaher et al., 1997) 9 to 18 Social Anxiety Scale for Children (La Greca, Dandes, Wick, Shaw, & Stone), Revised Version (La Greca & Stone, 1993), and Adolescent Version (La Greca & Lopez, 1998) 8 to 18 Social Phobia and Anxiety Inventory for Children (Beidel, Turner, & Morris, 1995, 1999) 8 to 17 Spence Children’s Anxiety Scale (Spence, 1998) 7 to 14 State–Trait Anxiety Inventory for Children (Spielberger, 1973) 8 to 15 Test Anxiety Scale for Children (Sarason, Davidson, Lighthall, & Waite, 1958) 8 to 17 27 items (15 items for NA subscale and 12 items for PA subscale). Assesses children’s sensitivity to positive and negative stimuli. Respondents rate adjectives (i.e., “sad,” “interested”) based on the frequency they felt that way during the past few weeks. 47 items. Assesses SAD, SOP, GAD, PD, OCD, and MDD. Respondents rate how true and frequent each anxiety symptom is for them. 37 items. Assesses anxiety symptoms. Yields Total Anxiety and Lie scores and three subscales: Physiological Anxiety, Worry/Oversensitivity, and Social Concerns/Concentration. Respondents endorse either yes or no to each item. 38 items. Assesses symptoms of SAD, GAD, SOP, and school phobia. Respondents rate severity of symptoms for the past 3 months 26 items (C) and 22 items (A). Assesses the subjective experience of social anxiety. Yields three subscales: Fear of Negative Evaluation, Social Avoidance and Distress in New Situations, and General Social Avoidance and Distress. Respondents rate how much each item is true for them. 26 items. Assesses the range of situations known to be distressful to youth with social phobia. Yields three subscales: Assertiveness/General Conversation, Traditional Social Encounters, and Public Performance. Respondents rate the degree to which they experience distress in each situation. 44 items. Assesses symptoms of SAD, SOP, OCD, PD-Agoraphobia, GAD, and Fears of Physical Injury. Respondents rate the frequency with which they experience each symptom. 20 items. Assesses chronic symptoms of anxiety. Yields two subscales: Anxiety-Trait assesses chronic cross situational anxiety; A-State assesses acute, transitory anxiety. Respondents rate the frequency with which they experience anxiety symptoms (e.g., “I am scared”). 30 items. Assesses anxiety in test-taking situations. Respondents rate whether they experience anxiety with respect to each test-taking situation. Internal consistency: NA subscale = .92; PA subscale = .87. Test–retest reliability: Not reported. Internal consistency: SAD = .72; SOP = .71; GAD = .83; PD = .79; OCD = .73; MDD = .78. Test–retest reliability: SAD = .75; SOP = .80; GAD = .79; PD = .76; OCD = .65; MDD = .77. Internal consistency: Total scale and subscales > .80. Test–retest reliability: Total scale and subscales range from .64 to .76. Internal consistency: Total scale = .93. Test–retest reliability: Total scale = .86; Subscales range from .70 to .90. Internal consistency: For child version, subscales range from .69 to .86. For adolescent version, subscales range from .76 to .91.Test–retest reliability: Subscales range from .69 to .86. Internal consistency: Total scale = .95. Test–retest reliability: Total scale = .86. Internal consistency: Total scale and subscales range from .60 to .92. Test–retest reliability: Total scale and subscales range from .45 to .60. Internal consistency: Subscales range from .80 to .90. Test–retest reliability: Subscales range from .31 to .71. Internal consistency: Total scale ranges from .82 to .90. Test–retest reliability: Total scale ranges from .44 to .82. Note: SAD = separation anxiety disorder; SOP = social phobia; GAD = generalized anxiety disorder; PD = panic disorder; OCD = obsessive–compulsive disorder; MDD = major depressive disorder; C = child; A = adolescent. 389 Table 4. Selected Parent and Teacher Rating Scales for Assessing Anxiety and Its Disorders in Youth Instrument Brief Description Reliability Behavior Assessment System for Children (Reynolds & Kamphaus, 1992) 126 to 148 items. Assesses behavior problems. Yields 20 scales and subscales (e.g., Internalizing, Anxiety). Child Behavior Checklist (Achenbach, 1991a), Teacher Report Form (Achenbach, 1991b) 118 items (P) and 120 items (T). Assesses positive and problem behaviors. Includes broadband subscales (Externalizing, Internalizing), and narrowband subscales (Withdrawn, Somatic Complaints, Anxious/Depressed, Social Problems, Thought Problems, Attention Problems, Delinquent Behavior, and Aggressive Behavior). 48 items (P) and 59 items (T). Assesses behavior problems and includes five subscales: Conduct Problems, Learning Problems, Psychosomatic, Impulsive–Hyperactive, and Anxiety. 40 items. Assesses behavior problems. Includes four subscales: Interpersonal Problems, Inappropriate Behaviors/Feelings, Depression, Physical Symptoms and Fears. 26 items. Assesses parents’ perceptions of the child’s trait anxiety. Internal consistency: Total scale and subscales range from .70s to .90s. Test–retest reliability: Total scale and subscales range from .70s to .90s. Internal consistency: Subscales range from .54 to .96. Test–retest reliability: Subscales range from .86 to .89. Conner’s Rating Scales–Revised P/T (Conners, 1990) Devereux Behavior Rating Scale–T School Form (Naglieri, LeBuffe, & Pfeiffer, 1993) State–Trait Anxiety Inventory for Children- Parent Report–Trait Version (Southam-Gerow, Flannery-Schroeder, & Kendall, 2002; Spielberger, 1973; Strauss, 1987). Internal consistency: Subscales range from .73 to.96. Test–retest reliability: Subscales range from .47 to .86. Internal consistency: Subscales range from .92 to .97. Test–retest reliability: Subscales range from .69 to .85. Internal consistency: Total scale for maternal and paternal reports range from .84 to .91. Test–retest reliability: Total scale for maternal and paternal reports range from .68 to .76. Note: P = parent; T = teacher. Table 5. Clinician Rating Scales for Assessing Anxiety and Its Disorders in Youth Instrument Children’s Yale–Brown Obsessive Compulsive Scale (Goodman et al., 1989; Scahill et al., 1997) Pediatric Anxiety Rating Scale (Research Units on Pediatric Psychopharmacology Anxiety Study Group, 2002) Clinician Severity Rating Scale for the Anxiety Disorders Interview Schedule for Children: Child and Parent Versions (ADIS: C/P; Silverman & Nelles, 1988; ADIS–IV: C/P; Silverman & Albano, 1996). Brief Description 10 items. Semistructured clinical interview administered to parent or child. Assesses obsessive–compulsive disorder severity. Two sections (obsessions, compulsion) yielding separate scores. Clinicians rate severity of symptoms based on frequency or duration, interference, distress, resistance, and control on a 5-point scale. Score > 15 indicates clinically significant obsessive–compulsive disorder. 50 items. Semistructured interview administered to parent and child. Assesses anxiety symptoms in six areas (Separation, Social Interactions or Performance Situations, Generalized, Specific Phobia, Physical Signs and Symptoms, and Other). Clinicians rate severity in each of seven dimensions (number of symptoms, frequency, severity of distress associated with anxiety symptoms, interference at home, severity of physical symptoms, and avoidance) on a 6-point scale. Score greater than 2 indicates clinically significant interference. Assesses level of severity/interference associated with each DSM-IV anxiety disorder assessed via the ADIS–IV: C/P. Clinicians rate (based on child and parent report) severity of symptoms based on interference in school, peer relationships, family life, and internal distress on a 9-point scale. Reliability Internal consistency: Total scale = .87. Inter-rater reliability: Total scale and subscales range from .66 to .91. Test–retest reliability: Not reported. Internal consistency: Total scale = .64. Inter-rater reliability: Total scale = .97; Severity dimensions range from .78 to .97. Test–retest reliability: Total scale = .55; Severity dimensions range from .37 to .59. Interrater reliability: .74. Test–retest reliability: ADIS–C = .89; ADIS–P = .87; Composite = .88. Note: DSM–IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994). 390 Table 6. Selected Rating Scales Used to Assess Variables Maintaining Anxiety in Youth Variable Parent–Child Relationship Parent–Child Relationship Rating Scale Parenting Behavior Inventory Child Report/Parent Report (Schludermann & Schludermann, 1970). Conflict Behavior Scale (Prinz, Foster, Kent, & O’Leary, 1979). Peer Relationships and Social Skills Friendship Questionnaire (Bierman & McCauley, 1987). Social Skills Social Skills Rating System Child & Parent Version (Gresham & Elliot, 1990). School Refusal Behavior School Refusal Assessment Scale (Kearney & Silverman, 1993); Revised Version (Kearney, 2002). Note: C = child; P = parent. Description Reliability 30 items. Assesses perceptions of parents’ behaviors toward child from child and parent report. Includes three subscales: Psychological Control, Acceptance, and Firm Control 20 items. Assesses problem areas (i.e., conflict) and positive and negative parent–child communications from child and parent report. 40 items (8 open-ended). Assesses peer interactions from child report. Includes three subscales: Positive Interactions, Negative Interactions, and Extensiveness of Peer Network. 44 items (C); 38 items (P). Assesses social skills. Includes 5 subscales: Empathy, Cooperation, Assertion, Responsibility, and Self-control. 16 items; revision 24 items. Assesses factors maintaining school refusal behavior from parent and child report. Includes four subscales: Avoidance of Fear-Provoking Situations, Escape from Aversive Social Evaluation Situations, Attention-Getting Behavior, and Positive Tangible Reinforcement. Internal consistency: Subscales range from .65 to .74. Test–retest reliability: Subscales range from .66 to .93. Internal consistency: Total scale ranges from .88 to .95. Test–retest reliability: Not reported. Internal consistency: Subscales range from .72 to .82. Test–retest reliability: Not reported. Internal consistency: Subscales range from .83 to .87. Test–retest reliability: Subscales range from .68 to .87. Internal consistency: Not reported. Test–retest reliability: Subscales range from .44 to .87. 391 392 Table 7. Interview Schedules and Rating Scales Used to Assess Youth Anxiety Treatment Outcome Study Barrett, Dadds, & Rapee (1996) Barrett (1998) Beidel, Turner, & Morris (2000) Cobham, Dadds, & Spence (1998) Cornwall, Spence, & Schotte (1996) Flannery-Schroeder & Kendall (2000) Gallagher, Rabian, & McCloskey (2004) Ginsburg & Drake (2002) Hayward et al. (2000) Heyne et al. (2002) Kendall (1994) Kendall et al. (1997) King et al. (1998) Last, Hansen, & Franco (1998) Manassis et al. (2002) Masia, Klein, Storch, & Corda (2001) Mendlowitz et al. (1999) Muris, Merckelbach, Holdrinet, & Sijsenaar (1998) Muris, Meesters, & van Melick (2002) Nauta, Scholing, Emmelkamp, & Minderaa (2003) Shortt, Barrett, & Fox (2001) Silverman, Kurtines, Ginsburg, Weems, Lumpkin, et al. (1999) Silverman, Kurtines, Ginsburg, Weems, Rabian, et al. (1999) Spence, Donovan, & Brechman-Toussaint (2000) ADIS–C/P DICA DISC K–SADS RCMAS yes yes yes yes yes yes yes yes yes yes yes yes STAIC FSSC-R CDI yes yes yes SPAIC yes yes yes yes yes yes yes yes CBCL TRF yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes Note: ADIS–C/P = Anxiety Disorders Interview Schedule: Child and Parent Version; DICA = Diagnostic Interview Schedule for Children; K–SADS = Schedule for Affective Disorders and Schizophrenia for School-Age Children; RCMAS = Revised Children’s Manifext Anxiety Scale; STAIC = State–Trait Anxiety Inventory for Children; FSSC–R = Fear Survey Schedule for Children–Revised; CDI = Children’s Depression Inventory; SPAIC = Social Phobia and Anxiety Inventory for Children; CBCL = Child Behavior Checklist; TRF = Teacher Report Form; Yes = Scale showed significant and positive changes from pre- to posttreatment. The following rating scales were also used in three or fewer studies: Children’s Coping Strategies Checklist (Sandler & Ayers, 1990), Children’s Negative Cognitive Error Questionnaire (Leitenberg, Yost, & Carroll-Wilson, 1986), Coping Questionnaire for Children (Kendall, 1994), Global Assessment of Functioning Scale (Jones, Thornicraft, & Coffey, 1995), Multidimensional Anxiety Scale (March et al., 1997; March, Sullivan, & James, 1999), Negative Affect Self-Statement Questionnaire (Ronan, Kendall, & Rowe, 1994), Revised Children’s Anxiety and Depression Scale (Chorpita, Yim, Moffitt, Umemoto, & Francis, 2000), Screen for Anxiety Related Emotional Disorders (Birmaher et al., 1997, 1999), Social Skills Questionnaire-Parent Version (Spence, 1995a), Social Worry Questionnaire Pupil Version (Spence, 1995b), Spence Children’s Anxiety Scale (Spence, 1998), and State Trait Anxiety Inventory for Children–Parent Version (Strauss, 1987). EVIDENCE-BASED ASSESSMENT OF ANXIETY is important to conduct empirical tests that link specific RCMAS scores to meaningful events and that define cutoff or threshold values that imply significantly heightened risks or benefits (Blanton & Jaccard, in press; Sechrest, McKnight, & McKnight, 1996). This also would require not just linking RCMAS scores to events that render the metric meaningful, but conducting the necessary generalizability studies to different populations, contexts, and so on. A similar set of concerns can be expressed about using the rating scales to assess treatment outcome. Table 7 shows the rating scales that have been used in the published youth anxiety treatment outcome studies. With some of the scales, such as the Child Behavior Checklist (CBCL), norms are used. However, norming mainly indicates a youth’s relative standing; it does not indicate a youth’s absolute standing on anxiety (Blanton & Jaccard, in press). More specifically, when the CBCL is used to assess treatment outcome, “clinically significant improvement” is defined as meeting a minimum criterion T score on the CBCL Internalizing scale of less than 70 (adjusted according to age norms; Kendall, 1994; Silverman, Kurtines, Ginsburg, Weems, Lumpkin, et al., 1999). In other words, cases that shift from being above this cutoff value to being below the cutoff value are said to have shown clinically significant improvement following treatment (see Kazdin, 1999; Kendall & Grove, 1988). There is no evidence, however, that youths with a score below 70 have fewer worries or display fewer avoidant behaviors than youths with a score above 70. That is, this shift on the CBCL, or the declining scores on the RCMAS, or any rating scale listed on the tables, from pre- to posttreatment does not truly inform whether the CBT had meaningful impact on the day-to-day functioning of the treated youth (see Kazdin, 1999). Blanton and Jaccard (in press) further pointed out that using Cohen’s d, a standardized index of effect size, does not serve to yield a more meaningful metric—all it does is rescale the unstandardized difference onto another arbitrary metric. What is necessary, therefore, when these scales are used in youth anxiety treatment outcome research is to have empirically established information about what different effect sizes, as indexed by Cohen’s d, mean in terms of “real” concrete changes. Kazdin (1999) provided examples such as meeting role demands, functioning in everyday life, and improvement in the quality of one’s life. With regard to using the rating scales to identify and quantify controlling or maintaining variables of anxiety, work in this area has only just begun. Prins (2001) and Boer and Lindout (2001), for example, summarized the research that has examined cognitive and family processes, respectively, that maintain anxiety as well the measures that have been used to assess these processes. With regard to potential mediators of changes, studies conducted to date have been post hoc in na- ture rather than designed from the onset as “mediational studies” (Kazdin & Nock, 2003; Weersing & Weisz, 2000), though research in this area is in progress (Silverman, 2003). One of the few studies that has evaluated a potential mediator of CBT in the youth anxiety area (i.e., Treadwell & Kendall, 1996) found that children’s negative self-statements, assessed using the Negative Affect Self-Statement Questionnaire (Ronan, Kendall, & Rowe, 1994) mediated improvement following individual CBT in child self-reported anxiety severity and a specific state-of-mind ratio but not in parent or teacher reports of externalizing or internalizing symptoms. Although the study by Treadwell and Kendall represents an important initial step in the youth anxiety research on evaluating mediators or mechanisms of positive treatment response, it does not meet the criteria of establishing the time line between the mechanism and behavior changes (Kazdin & Nock, 2003; Weersing & Weisz, 2002), or the additional requirements delineated by Kazdin and Nock (2003). More research is sorely needed in this area. Certainly, however, the majority of the rating scales listed in the tables have the potential to be used in the assessment of contextual variables that influence the maintenance of anxiety and its disorders in youths as well as in the assessment of therapy mediators and moderators. It is now up to the investigators in the field to take these measures and use them accordingly for these purposes. Some additional comments specific to the youth, teacher, and clinician rating scales are in order. Regarding youth self-rating scales, despite their apparent advantages (e.g., quick, efficient, inexpensive), it is reasonable to presume that some anxious youths would be reluctant to self-disclose about their personal anxious reactions. Research findings back this up. The RCMAS offers an advantage that sets it apart from the other anxiety rating scales in that it contains not only a Total Anxiety scale but also a Lie scale. The RCMAS Lie scale, a downward extension of the Lie scale on the adult version of the Manifest Anxiety Scale, was derived from the Social Desirability/Lie scale of the Minnesota Multiphasic Personality Inventory. Containing items such as “I never get angry,” “I like everyone I know,” and “I am always kind,” the Lie scale has been used as an indicator of social desirability (Dadds, Perrin, & Yule, 1998; Reynolds & Richmond, 1985) or defensiveness (e.g., Joiner, 1996), reflecting a tendency to present oneself in a favorable light or deny flaws and weaknesses that others are usually willing to admit. Research using the RCMAS Lie scale in unselected school samples (Dadds et al., 1998) and clinic-referred anxious samples (Pina, Silverman, Saavedra, & Weems, 2001) reveals that younger children score significantly higher on the Lie scale than older children (Dadds et al., 1998; Pina et al., 2001); African American youths score significantly higher than European American youths (Dadds et al., 1998), and Hispanic American youths 393 SILVERMAN AND OLLENDICK score significantly higher than European American youths (Pina et al., 2001). No significant gender differences have been observed in Lie scale scores (Hagborg, 1991; Pina et al., 2001; Reynolds & Richmond, 1985). These findings underscore the need for clinicians and researchers to recognize that certain groups of anxious children and adolescents are more likely to evidence social desirability when using anxiety rating scales than are other groups. For example, when assessing a young anxious child, if the child endorses four Lie scale items (the younger children’s mean Lie score in Pina et al., 2001) or more, it may be worthwhile to question the validity or accuracy of the child’s self-reports of anxiety and consider alternative sources. It further underscores the need to emphasize to anxious youth that there are no right or wrong answers during the assessment process. Similar pressure to please and to be seen in a favorable light may be placed on children and adolescents with anxiety disorders during other assessment strategies such as behavioral observations, though the issue has not been studied. Teacher ratings, like parent and child ratings, generally show poor correspondence to other informants’ ratings (Achenbach, McConaughy, & Howell, 1987). There also is general consensus in the field that teachers are less helpful for assessing internalizing problems, such as anxiety, than they are for externalizing problems (Loeber, Green, & Lahey, 1990). This makes sense in light of the overt versus covert nature of externalizing and internalizing behavior problems, respectively. That is, teachers can more readily tell when a child is out of the chair or is calling out of turn (an externalizing problem). It is not as obvious when a child is experiencing severe internal distress because he or she is about to be called on (an internalizing problem). Obtaining teacher ratings also poses methodological difficulties in that as children enter the middle school and high school years, they have multiple teachers; so determining which teacher to ask to complete the forms is not readily apparent. The time of the year when the assessment occurs poses additional difficulties (e.g., the summer months, early in the school year). Perhaps partly for these reasons, teacher ratings have been infrequently used in the youth anxiety research area and therefore have a thin evidence base. The clinician rating scales presented in Table 5 are all relatively new to the field, and their evidence base also is therefore thin. In light of the response biases that may occur with child and parent rating scales (e.g., social desirability), however, clinician rating scales can serve to supplement other informants’ reports in potentially useful ways. For example, the recently developed PARS (Research Units on Pediatric Psychopharmacology Anxiety Study Group, 2002) was designed to assess the frequency, severity, and associated impairment across SAD, SOP, and GAD symptoms in children and adolescents (ages 6 to 17 years), rather 394 than assessing impairment of each individual anxiety disorder as does the clinician severity rating scale of the ADIS: C/P (Silverman & Albano, 1996). The developers of the PARS note that in light of the high rates of comorbidity observed among the anxiety disorders, this type of global rating of impairment, similar to the Children’s Global Assessment Scale (Bird, Canino, Rubio-Stipec, & Ribera, 1987), could be useful. As Table 5 shows, although the internal consistency of the PARS was found to be satisfactory, its retest reliability needs further examination (e.g., retest reliability = .55 for the total scale score using a retest interval of a mean of 24.7 +/– 14.7 days; though this likely reflects in part the changing nature of children’s display of anxiety over time). Also needing further examination is the scale’s convergent and divergent validity. With regard to the latter, although the observed correlations were in the expected directions (in terms of being positively correlated with ratings of internalizing symptoms and negatively correlated with externalizing symptoms), this was more true when the PARS’s ratings were correlated with other clinician ratings rather than with other sources’ ratings, such as children’s ratings on the MASC. This was true for both pretreatment as well as posttreatment rating scores, suggesting some potential, though limited, utility of the PARS to assess treatment responsiveness. In summary, rating scales have been frequently used in child and adolescent anxiety research. They have been studied frequently with regard to reliability (interrater, internal consistency), and many of them have been studied for concurrent and divergent validity. Less psychometric information (reliability, validity) is available on all of these ratings scales’ psychometrics with clinically anxious samples of youths. Youth and parent rating scales, especially the RCMAS for youth and the CBCL for parents, are the most widely used and evaluated. Their most frequent usage has been to identify and quantify symptoms and for evaluating treatment outcome. Despite their wide usage and the fact that in most treatment outcome studies the scales show sensitivity to change, the scores obtained on these rating scales are on an arbitrary metric. Considerably more research is needed to determine the meaning or practical value of a youth’s score on these scales, as well as the meaning or practical value of observed changes on these scales during the course of a treatment outcome study. Finally, although rating scales have considerable potential to inform the field about maintaining or controlling variables of anxiety as well as mediators and moderators of therapy outcome, research in this area has only just begun. Direct Observations Direct observation procedures have been used extensively in the pediatric psychology area, such as in EVIDENCE-BASED ASSESSMENT OF ANXIETY the filmed modeling research where it has been found that children’s observed distress prior to surgical procedures can be significantly reduced by watching films (e.g., Melamed & Siegel, 1975). Direct observations also have been used to assess anxiety in young, preschool-age children (e.g., Glennon & Weisz, 1978) given the potential limits (e.g., social desirability) noted previously when it comes to obtaining self-reports from younger populations. Direct observations also were used in the early days of behavior therapy when the technology of behavioral assessment procedures, particularly behavioral avoidance tasks, were being designed and evaluated for use primarily with individuals with phobias, though not necessarily clinic-referred phobia cases (e.g., Kornhaber & Schroeder, 1975; Murphy & Bootzin, 1973). In some studies, temporal stability was evaluated over minutes (e.g., Kornhaber & Schroeder, 1975). When assessed over minutes, stability was acceptable. When assessed over days, stability or reliability deteriorated (e.g., Murphy & Bootzin, 1973). Also, in some of these studies (e.g., Kornhaber & Schroeder, 1975; Murphy & Bootzin, 1973), how the child behaved during the observation task was evaluated in relation to the child’s self-report, with reasonable convergence usually found. Direct observational procedures have been far less used with DSM cases of clinical child and adolescent anxiety. Table 8 provides a summary of studies that we could locate that have employed and evaluated the psychometrics of direct observation tasks, with mainly clinic-referred anxious youths. The observations were conducted in clinic or experimental settings in all the studies listed in the table. Further examination of Table 8 reveals that although direct observations are designed particularly well for the purposes of identifying and quantifying specific fear and anxiety symptoms and behaviors, such as avoidance, few youth anxiety studies have actually used them for this purpose. An example of a study that did is Ost, Svensson, Hellstrom, and Lindwall (2001), in which, inasmuch as the behavioral avoidance tasks consisted of a series of graduated steps, the percentage of steps the youth accomplished was recorded. Direct observations have been used more frequently in youth anxiety research for evoking fear and anxiety reactions in youths (i.e., in an in vivo exposure) and then having youths subjectively rate their levels of fear or anxiety, having trained observers subjectively rate the youths’ levels of fear or anxiety, or both. In some studies, observers’ subjective ratings were obtained not only by providing the observers with global rating scales (e.g., a Likert rating scale from 1 to 5), but also by providing the observers with behavioral dimensions to help assist them in making their subjective ratings (Kendall, 1994). Direct observation procedures also have been used in a small number of clinical trials (e.g., Barrett, Dadds, & Rapee, 1996; Beidel, Turner, & Morris, 2000; Kendall, 1994) to evaluate treatment outcome, with uneven results (e.g., Beidel et al., 2000, and Kendall, 1994, reported improvements, but Barrett et al., 1996, did not find significant differences in family observation tasks depending on whether youths received individual CBT or a parent involvement CBT). In addition, direct observation procedures have been used to assess the controlling or maintaining variables of anxiety, most typically family interaction patterns. Table 8 shows the three main types of tasks that have been used in the youth anxiety area: (a) social evaluative tasks, (b) behavioral avoidance tasks, and (c) parent–youth interaction tasks. With regard to social evaluative tasks (Beidel et al., 2000; Kendall, 1994), participants are informed of the evaluative nature of the task and are given standard behavioral assertiveness instructions. For example, Beidel et al. invited children and adolescents to read aloud a story in front of a small group and were told to “Respond as if the scene were really happening.” With regard to behavioral avoidance tasks, Ost et al. (2001) exposed children and adolescents to their feared stimuli under relatively controlled and replicable conditions in the clinic setting. For example, for fear of snakes, youths were asked to enter a room where a live snake was enclosed in a glass container and to remove the lid from the container and pick up the snake and hold it for 10 sec. With regard to the parent–youth interaction tasks (e.g., Hudson & Rapee, 2002), parents and youths are observed while engaging in problem-solving situations. For example, Hudson and Rapee conducted observations of “normal” and anxious youths and their siblings while separately completing a set of tangram/ puzzle tasks designed to be slightly too difficult to complete in 5 min. Of interest was the degree of parental involvement during the task (e.g., degree of unsolicited help, degree to which the parent physically touched the tangram piece). Another point worth noting about the studies listed in Table 8 is that experimenter instructions vary with respect to how much demand is placed on the youth, with some instructions exerting high demand (e.g., “Make this talk as interesting as possible; we will be listening”) and with some exerting less demand (e.g., “Tell us about yourself”). The explicit instructional set is not given in all of the studies, and how this instructional set influences studies’ findings has not been studied with child and adolescent anxious participants. It is possible that the types of significant group differences found with the RCMAS Lie scale (or social desirability) may play a role in how different groups of children react to high versus low instructional sets. Relatedly, although these procedures have been used with a wide range of age groups, the equivalence of the tasks across age groups has not been established (Vasey & Lonigan, 2000). 395 Table 8. Sample of Observation Tasks Conducted With Anxious Youth Study N Sample Age Observation Tasks Instructions Rater Reliability Social Evaluative Tasks Ferrell, Beidel, & Turner (2004) 58 SOP 7 to 12 years (1) role play with peer (2) read aloud task for 10 min “Respond as if the scene were really happening” “Read aloud the story of Jack and the Beanstalk” Youth and Observer Youth and Observer Interrater reliability: .89 (skills) Interrater reliability: .87 (anxiety) Beidel, Turner, & Morris (2000) 67 SOP 8 to 12 years (1) role play with peer (2) read aloud task for 10 min “Respond as if the scene were really happening” “Read aloud the story of Jack and the Beanstalk” Youth and Observer Interrater reliability: .89 (skills) Kendall (1994) 47 SAD, OAD, AVD 9 to 13 years 5-min talk “Tell us about yourself” Observer Interrater reliability: .82 Hamilton & King (1991) 14 SP 2 to 11 years in vivo exposure “Close interaction with dogs” Observer Test–retest reliability: .97 Ost, Svensson, Hellstrom, & Lindwall (2001) 60 SP 7 to 17 years in vivo exposure “Do your very best, you can terminate the test at any point” Youth No reliability reported 68 OCD, SAD, GAD, SOP, SP, PD, AG 7 to 15 years (1) 5-min warm-up parent–youth dyad (2) 5-min conflict conversation “Come to a consensus decision about characteristics of an ideal person” “Talk about something you argue about and attempt to reach an agreement or solve the problem” “Talk about something that made the child anxious or worried” Observer Interrater reliability: Values range from .88 to .94. Behavioral Avoidance Tasks Parent–Child Interaction Tasks Moore, Whaley, & Sigman (2004) (3) 5-min anxiety conversation Hudson & Rapee (2002) 37 20 Woodruff-Borden, Morrow, Bourland, & Cambron (2002) Cobham, Dadds, & Spence (1999) 57 73 GAD, SP, SOP, SAD, PD, OCD nonclinic 7 to 16 years 5-min parent–youth dyad while working on puzzle “The puzzle is a test of the child’s cognitive ability; you can help if you think it’s needed” Observer Interrater reliability: .83 PD, SP, PD with AG, OCD, GAD, PTSD 6 to 12 years (1) 10-min parent–youth dyad working on unsolvable anagrams “Do the best you can with the list of word puzzles; we will be back in 10-min to see how many you have correct” Observer Interrater reliability: Values range from .80 to 1.00 (2) 10-min parent–youth dyad talking about themselves “Give a speech about yourselves in front of the camera” (1) 3-min talk Youth and Parent (2) three 5-min talk youth– parent (3) 3-min talk (optional) “Make this talk as interesting as possible; we will be listening” “How he or she felt, prepare for talk, discussion for second talk” “Talk about your fear" Interrater reliability: .93 (skills); Interrater reliability: .70 (anxiety) SAD, SP, OAD, GAD, SOP, AG 7 to 14 years Dadds, Barrett, Rapee, & Ryan (1996) 66 SAD, SP, OAD, SOP 7 to 14 years 5-min parent–youth dyad to generate problem-solving solutions Youth was asked to interpret and respond to a physical and social situation first alone and then with parents Observer Interrater reliability: Values range from .72 to .99 Barrett, Dadds, & Rapee (1996) 79 SAD, OAD, SOP 7 to 14 years 5-min parent–youth dyad to generate problem-solving solutions Youth was asked to interpret and respond to a physical and social situation first alone and then with parents Observer Interrater reliability: 1.00 Siqueland, Kendall, & Steinberg (1996) 17 27 OAD, SAD, nonclinic 9 to 12 years 4- to 6-min talk youth–parent “Read the topic printed on a card and discuss the topic” Observer Interrater reliability: Values range from .85 to .91 Note: SOP = social phobia; GAD = generalized anxiety disorder; SP = simple phobia disorder; SAD = separation anxiety disorder; PD = panic disorder; OCD = obsessive–compulsive disorder; OAD = overanxious disorder; AVD = avoidant disorder; AG = agoraphobia; PD with AG = panic disorder with agoraphobia; PTSD= posttraumatic stress disorder. EVIDENCE-BASED ASSESSMENT OF ANXIETY Finally, in almost all of the studies, reliability was assessed in terms of interrater agreement using percentage agreement, Pearson correlations, kappa coefficients, internal consistency, or intraclass correlation coefficient. Each of these reliability statistics has strengths and weaknesses (see Mitchell, 1979), and conclusions obtained from a given study need to be drawn judiciously depending on the reliability statistic used. Research on observational procedures’ retest reliability is particularly scarce. In summary, direct observations have been most frequently used to obtain subjective ratings of youths and observers when the youth is either in a fear-provoking situation or in a family interaction task. When used in family tasks, the observations are used to assess contextual (family) variables that may serve to maintain anxiety. Surprisingly, direct observations have been less frequently used to identify and quantify specific anxious symptoms and behaviors and also less used to assess treatment outcome. In addition, there currently is an absence of a standardized task and coding procedure, which makes it difficult to generalize across studies (Barrios & Hartmann, 1997). Critical for further study is whether the time and cost involved in the use of direct observations have a knowledge development “payoff.” That is, do direct observation procedures possess incremental validity over simply using self-reports or self-monitoring (discussed later)? Despite the important questions that need to be answered, we do believe that direct observational procedures have clinical utility. For example, they are likely to yield helpful conceptual information about the nature of family interactions among anxious children or just “how far children can go” when it comes to interacting with a feared object or event. Given the potentially useful conceptual information that can be gained from these procedures, we encourage their continued use and evaluation. Self-Monitoring Self-monitoring procedures have often been viewed as a more efficient and easier way to accomplish the same goals as direct observations—that is, to identify and quantify symptoms and behaviors, to identify and quantify controlling variables, and to evaluate and monitor treatment outcome. In the youth anxiety area, self-monitoring procedures have been used for these purposes (see Silverman & Kurtines, 1996). With regard to treatment outcome evaluation, self-monitoring data have been used in a number of single case study designs as a baseline that is later used to document behavior change during the treatment phase (e.g., Eisen & Silverman, 1998; Ollendick, 1995). They have not been used as outcome measures in the clinical trials. Although self-monitoring is relatively common in practice among behaviorally oriented clinicians, little has been done in the child and adolescent anxiety research area to evaluate its feasibility and psychometric properties. An exception is Beidel, Neal, and Lederer (1991), who devised and evaluated the feasibility (i.e., child compliance), reliability, and validity of a daily diary for use in assessing the range and frequency of social-evaluative anxious events in elementary school children (N = 57; n = 32, test anxious; n = 25, nontest anxious) during a 2-week assessment phase. Relatively structured in nature, the daily diary listed events such as “I had a test” and “The teacher called on me to answer a question,” as well as a list of potential responses to the occurrence of the events, including positive (e.g., “I practiced extra hard, told myself not to be nervous, it would be okay”), negative (e.g., “I cried, got a headache or stomachache”), and neutral (e.g., “I did what I was told”) behaviors. The children also rated the degree of distress they experienced using the Self-Assessment Manikin (Lang & Cuthbert, 1984), which is a pictorial 5-point rating scale that depicts increasing degrees of anxious arousal. With regard to feasibility or compliance, with no incentives offered, the mean number of days the diary was completed ranged from 7.9 to 11.5 days, though only 31% to 39% of the children complied for the full 2 weeks. Retest reliability was found to be modest, but that is probably because the events listed on the diary likely show true fluctuations. Evidence for validity was demonstrated in that the test-anxious children reported significantly more emotional distress and more negative behaviors such as crying or behavioral avoidance. Despite Beidel et al.’s (1991) limitation of not having an outside validity check for the children’s daily recordings (e.g., parent ratings or independent observer), the study is an important one in providing some basic psychometric data of self-monitoring forms for use in assessing childhood anxiety. The authors suggested that diverse diaries be developed that are tailored to other, specific anxiety concerns of children (e.g., separation situations for children with SAD). This suggestion has not been followed up by other investigators, though it would seem a potentially useful way to improve self-monitoring procedures even further with child anxious populations. In the meantime, it appears that a relatively structured self-monitoring form possesses some degree of evidence, though whether this type of structure is necessary for older children and adolescents is unknown. As with direct observation procedures, additional research is needed on self-monitoring procedures (i.e., feasibility, reliability, validity). In addition, although the data obtained from self-monitoring have been found to be sensitive to change in single case study designs, whether treatment sensitivity would be found in a large-scale randomized trial is uncertain. Indeed, given the extensive encouragement and enhanced motivational efforts that need to be exerted to get young 397 SILVERMAN AND OLLENDICK people to comply with filling out self-monitoring forms, it is possible that exerting such efforts is more difficult in large randomized trials; and so the treatment sensitivity of self-monitoring data observed in the single case studies may not emerge in the clinical trials. This is an empirical question that would be worth answering. Nevertheless, self-monitoring procedures have clinical utility in terms of yielding helpful conceptual information (e.g., the specific situations that elicit anxiety in a child, the child’s cognitions when faced with a specific object or event), so we encourage their continued use and evaluation. Summary The overview provided in this section presents the most frequently used assessment methods and instruments for use with youths with anxiety disorders. The overview also indicates the main purposes or goals of assessment for each of these methods and instruments and where the evidence is most abundant when it comes to how well these methods and instruments can successfully accomplish these goals. To briefly summarize, interview schedules have been used most frequently for diagnosing, identifying, and quantifying symptoms and for assessing for diagnostic recovery in treatment outcome research. Among the interview schedules available, the ADIS: C/P (Silverman & Albano, 1996) has been used in most of the youth anxiety research studies, and it also has been evaluated with respect to both reliability and validity of DSM–IV anxiety diagnoses. Interview schedules also would appear to have treatment utility, though this requires further empirical verification. Rating scales have been used most for identifying and quantifying symptoms and behaviors and for evaluating treatment outcome. They also may be useful for screening purposes, as summarized in the next section. The RCMAS has been most frequently used for these purposes, with the CBCL being used primarily for evaluating treatment outcome. The psychometric properties of many of these measures have been evaluated mainly for nonclinic referred anxious children and adolescents, with less evaluative work done on clinic-referred anxious youths. Teacher- and clinician-completed rating scales of child anxiety have been less used in clinical child and adolescent anxiety assessment research. New clinician rating scales, such as the PARS, suggest that such scales may be useful supplements to parent and child reports. The metrics of all of the rating scales need to be further tested and tied to real-life practical events. Although the use of ratings scales is the most efficient way to assess for mediators and moderators of treatment and to assess the contextual aspects of anxiety and its disorders, work in this arena is limited. 398 Direct observational procedures have been used in several studies, and they are likely to have clinical utility, especially in terms of yielding conceptually useful information. Interestingly, when they have been used, subjective ratings from the youth, observers, or both are most frequently obtained. Using direct observation to actually quantify specific symptoms or behaviors of anxiety has been less frequently done. There is a lack of information about their retest reliability and incremental validity, with the latter seeming particularly important to determine in light of the investigator and participant burden that observational procedures impose. Self-monitoring procedures also would seem to yield conceptually useful information. To date, however, only one assessment study (Beidel et al., 1991) has evaluated the feasibility, reliability, and validity of self-monitoring procedures with anxious children. Some Additional Issues In this section, we discuss what more might be done to move toward an evidence-based assessment approach by focusing on several additional assessment issues that have begun to be tackled empirically by investigators in the youth anxiety area and where a body of research studies has begun to accumulate. This has been done mostly within the context of self-report assessment methods (diagnostic interviews and rating scales) and within the context of the assessment goals of screening and diagnosing. More specifically, we focus on discriminating between anxiety and other constructs, screening for anxiety disorders, and the handling of discrepant information from multiple informants. Discriminating Between Anxiety and Other Constructs With the exception of interview schedules, which were developed specifically for assessing differential diagnosis, only the rating scales have been examined with regard to how well they can discriminate between youths with anxiety and other constructs (and other disorders). Having assessment instruments that can accurately discriminate is of particular importance given the common observation that multiple disorders tend to co-occur within the same child and at the same time (i.e., comorbidity). Estimated rates of comorbidity among youths with clinical disorders, in general, run as high as 91% in clinic samples (e.g., Angold & Costello, 1999) and up to 71% in community samples (e.g., Woodward & Fergusson, 2001). Although some of the observed high rates of comorbidity reflect assessment artifacts (or other artifacts, such as referral bias), there is considerable evidence to the observed comorbidity (e.g., Beiderman, Faraone, Mick, & Lelon, 1995; Selig- EVIDENCE-BASED ASSESSMENT OF ANXIETY man & Ollendick, 1998). This underscores the need to carefully assess for different disorders. Within the anxiety disorders, the particular comorbid patterns most critical to assess for are the following (arranged from most observable and predictable): primary anxiety disorder diagnoses co-occurring first with other anxiety disorders, second with depression, and third with the externalizing disorders (ADHD, oppositional defiant disorder, conduct disorder; Kovacs & Devlin, 1998). Although the many reasons for comorbidity are not fully understood (Angold & Costello, 1999), anxious youths who are comorbid with another disorder, especially an affective disorder, are more severely impaired than youths with either disorder alone, their problems are more likely to persist over time, and they are more likely to be refractory to behavior change (see Saavedra & Silverman, 2002; Seligman & Ollendick, 1998). Thus, it is important that assessment measures be able to discriminate among the various comorbid disorders, particularly between anxiety and depression. The issue has not been studied with most of the measures listed in the tables. It has been studied most extensively with the RCMAS. In an early study, using a multitrait–multimethod design (Campbell & Fiske, 1959), which allows for the simultaneous evaluation of convergent and divergent validity, Wolfe et al. (1987) correlated inpatient children’s RCMAS total scores (N = 102; ages 6 to 16 years) with their scores from another scale, the State–Trait Anxiety Inventory for Children (STAIC) and with depression (Children’s Depression Inventory), as well as with scores from a teacher rating scale. The convergent validity of the RCMAS was supported by a significant and positive correlation between the RCMAS total scores and the STAIC trait scores, but the correlation between the RCMAS total scores and the teacher-rated anxiety scores was not significant. However, the total scores on the RCMAS, the STAIC–Trait, and the Children’s Depression Inventory were all intercorrelated. Wolfe et al. (1987) noted that these findings are due in part to the overlap of many of the items contained on each rating scale; however, they also discuss the findings in terms of the negative affectivity construct. This construct has received increased attention over the years, and more is said about it shortly. Several studies have examined the ability of the RCMAS to discriminate between youths with anxiety disorders and youths with no disorders or youths with other disorders. Mattison, Bagnato, and Brubaker (1988) reported that in a sample of 8- to 12-year-old outpatient boys, those diagnosed with overanxious disorder according to the DSM–III (American Psychiatric Association, 1980) scored significantly higher than boys with dysthymia or attention deficit disorder on the Worry/Oversensitivity and Physiological factor scales of the RCMAS. On the other hand, Hodges (1990) in her examination of several child self-rating scales, including the RCMAS, in anxious, depressed, and conduct-disordered psychiatric inpatients (ages 6 to 13 years), reported that the RCMAS could not differentiate among these three groups. Perrin and Last (1992), using a sample of 213 outpatient boys (ages 5 to 17 years), showed that the total score on the RCMAS, along with each of its three subscale scores, differentiated boys with anxiety disorders from boys with no disorders. However, the scales did not differentiate between boys with an anxiety disorder and boys with ADHD. Overall, these findings indicate that the ability of the RCMAS to discriminate among groups is questionable. A recent meta-analysis of 43 published studies by Seligman, Ollendick, Langley, and Baldacci (2004) supported this conclusion. A large effect size was found when the RCMAS was used to compare youth with an anxiety disorder to youth with no disorder, as was initially shown by others (e.g., Perrin & Last, 1992). However, when comparing youths with anxiety disorders to those with other disorders, the picture was more mixed. The RCMAS was found to be useful when discriminating between youths with anxiety disorders and youths with oppositional and conduct problems but not between youths with an affective disorder. Thus, its discriminant validity was only partially supported. In the interview section, we reported how diagnoses obtained using the ADIS: C/P converged and diverged as expected with ratings on the MASC (Wood et al., 2002). Similar encouraging findings have appeared with the Screen for Anxiety and Related Emotional Disorders (SCARED; Birmaher et al., 1997, 1999). In a sample of 341 consecutively referred children (M age = 14.5 years old), Birmaher et al. (1997) found that based on the items endorsed, children with anxiety disorders could be differentiated from children with nonanxiety psychiatric disorders, and children with pure anxiety disorders could be differentiated from children with depression and disruptive behavior problems. Moreover, based on symptom reports on the SCARED, children with different types of anxiety disorders could be differentiated. Specifically, children with PD, GAD, and SAD, respectively, could be differentiated from children with other anxiety disorders. Using a revised version of the SCARED, Birmaher et al. (1999) conducted a replication of Birmaher et al. (1997) using a sample of 190 outpatient children and adolescents (ages 9 to 18 years) and 166 parents. Youths with anxiety disorders could be differentiated from youths with nonanxious psychiatric disorders based on their self-ratings on this scale. Youths’ selfratings on the SCARED also differentiated youths with anxiety disorders from youths with pure depression as well as youths with disruptive behavior disorders. Self-ratings on each of the SCARED’s subscales also 399 SILVERMAN AND OLLENDICK were found to differentiate among several of the anxiety disorders based on the corresponding subscale. That is, self-ratings on the Panic/Somatic subscale differentiated youths with PD from youths with other anxiety disorders; self-ratings on the GAD and SOP subscales differentiated youths with these respective disorders from youths with other anxiety disorders. Parent ratings on the Separation Anxiety subscale differentiated youths with SAD from youths with other anxiety disorders. The discriminant validity of youths’ and parents’ ratings of youths’ fears on the Revised Fear Survey Schedule for Children (FSSC–R; Ollendick, 1983) was evaluated by Weems, Silverman, Saavedra, Pina, and Lumpkin (1999) using 120 children and adolescents (ages 6 to 17 years) who met for a primary diagnosis of SOP, simple or specific phobia of the dark or sleeping alone, animals, or shots or doctors. Results indicated that both the youth and parent completing the fear inventory were similarly useful in differentiating among the specific types of phobias. Moreover, item analyses indicated that youth-completed FSSC–R items could discriminate among the different simple and specific phobias but not SOP, and that parent-completed FSSC–R items could discriminate not only the different simple and specific phobias but also SOP. These findings build on a previous study conducted by Last, Francis, and Strauss (1989) who found that when using the FSSC–R, clinically referred children with SAD, overanxious disorder, and school phobia could be discriminated qualitatively using an item analysis based on the most commonly reported fears. A few studies have suggested that a scale’s discriminant validity varies depending on whether the scale’s total score is used versus its subscale scores. Lonigan, Carey, and Finch (1994), for example, found the Worry/Oversensitivity subscale of the RCMAS to distinguish between hospitalized youths with anxiety disorders and youths with a major affective disorder; the RCMAS Total score and the Fear/Concentration and Physiological Anxiety subscales did not differentiate between the two groups. Similarly, whether Total scale scores or subscale scores of the Childhood Anxiety Sensitivity Index (Silverman, Fleisig, Rabian, & Peterson, 1991) are used influence the extent to which anxiety and depression can be differentiated in youths (e.g., Joiner et al., 2002; Weems, Hammond-Laurence, Silverman, & Ferguson, 1997) as well as youths with SOP versus other phobic and anxiety problems (Silverman, Goedhart, Barrett, & Turner, 2003). In summary, the FSSC–R (completed by both child and parent) appears to have preliminary support for discriminating among different types of phobias. In addition, although the RCMAS may be used to differentiate youth with anxiety disorders from youth with no disorders, caution is warranted in using the RCMAS to 400 differentiate youth with other disorders. There is some evidence that the Worry/Oversensitivity subscale might do a better job than the Total RCMAS scale or the other two subscales in differentiating anxiety from other constructs, particularly depression, but further research is needed to establish this point. The SCARED and MASC have somewhat more positive supportive evidence with regard to their ability to differentiate anxiety from other disorders as well as to differentiate among some of the anxiety disorders, though the amount of research conducted is quite scant. Similar concerns about differentiating between anxiety and depression have been raised as well with the CBCL’s Internalizing broadband scale and the Anxious/Depressed narrowband subscale in that recent research has shown that both subscales appear to measure a more global construct (i.e., negative affect) common to both mood and anxiety disorders (Chorpita, Albano, & Barlow, 1998; Chorpita & Daleiden, 2002). In light of the mixed findings in rating scales’ abilities to discriminate anxiety disorders from other disorders, particularly depression, investigators have recently drawn on the tripartite model (e.g., Clark & Watson, 1991) in developing scales that might perform better with regard to discriminating between these two constructs. According to the tripartite model, anxiety and depression share a significant but nonspecific component of generalized distress referred to as “negative affect.” Examples of negative affective symptoms include anxious or depressed mood, poor concentration, sleep difficulties, and irritability. “Positive affect” also needs to be considered, in that depression is characterized by low positive affect (e.g., not being able to experience pleasure, cognitive and motor slowing). Low positive affect is generally not a component of anxiety; however, research with adult patients has found an equally strong association between low positive affect and SOP (Watson, Clark, & Carey, 1988). Finally, there is physiological hyperarousal, which was originally hypothesized as a factor specific to anxiety (Clark & Watson, 1991), but recent findings with youth (Chorpita & Daleiden, 2002) have mirrored findings with adults (Brown, Chorpita, & Barlow, 1998). Namely, physiological hyperarousal shows the strongest relation with PD symptoms, followed by depression and then GAD symptoms. Thus, youth self-rating scales, summarized in Table 3, drawn from the tripartite model (e.g., Clark & Watson, 1991) have been developed. These include the Revised Child Anxiety and Depression Scale (Chorpita, Yim, Moffitt, Umemoto, & Francis, 2000), an adaptation of the Spence Children’s Anxiety Scale (Spence, 1997), the Positive and Negative Affect Scale for Children (Laurent et al., 1999), the Physiological Hyperarousal Scale for Children (Laurent, Catanzaro, & Joiner, 2004), and the Affect and Arousal Scale EVIDENCE-BASED ASSESSMENT OF ANXIETY (Chorpita, Daleiden, Moffitt, Yim, & Umemoto, 2000; Daleiden, Chorpita, & Lu, 2000). Findings obtained thus far with each of these scales suggest that each of them do a better job than the anxiety (or depression) rating scales in discriminating between anxiety and depression. However, each of them also appears to be able to accomplish certain tasks relative to others. As Chorpita and Daleiden (2002) explained, the Affect and Arousal Scale may be preferred for assessing youths’ general sensitivity to negative emotions and the experience of arousal. For assessing youths’ experience of negative and positive emotions in a group of children and adolescents, the Positive and Negative Affect Scale for Children may be preferred. It appears then that the complexities and divergent findings that exist with the anxiety rating scales exist as well with the tripartite-based rating scales. Further research using multiple criterion variables assessed from multiple informants is needed to help clarify the tripartite model, and the instruments designed to assess this model, in children and adolescents (Chorpita & Daleiden, 2002). In addition, although these scales hold theoretical interest, it is important in the future for researchers to focus greater attention on demonstrating the clinical relevance of this area of study, as Barlow et al. (2004) have begun to demonstrate in their work with anxiety-disordered adults. Screening and Diagnostic Accuracy of Anxiety Assessment Measures Related to the issue of discriminating between anxiety and other constructs and disorders is the issue of the diagnostic accuracy of anxiety assessment measures for screening purposes. Data on the sensitivity (the percentage of individuals who receive the diagnosis who have been positively identified by the rating scale, or true positives) and specificity (the percentage of individuals who do not receive the diagnosis and who are not identified by the rating scale as anxious, or true negatives) of the various rating scales are scarce, particularly so in non-White child and adolescent samples. Also scarce are the converse probabilities. Specifically, positive predictive power means that an individual has the disorder given that he or she obtained a positive test result. Negative predictive power reflects the probability of the individual not having the disorder given a negative test result. Other than rating scales, how well any of the other assessment methods screen for youth anxiety has not been examined. The little work that has been conducted with rating scales suggests that scales designed to assess similar anxiety constructs may yield different sensitivity and specificity findings. A case in point is research using the SASC–R (La Greca & Stone, 1993) and its adolescent version (Social Anxiety Schedule for Adolescents [SAS–A]; La Greca & Lopez, 1998), and the SPAI–C (Beidel, Turner, & Morris, 1995). The former is based on the theoretical conceptualizations of social anxiety of Watson and Friend (1969); the latter is based on the specific symptomatology of SOP as described in DSM–IV. Perhaps it is not surprising then that they yield different findings, as they were not designed to assess identical aspects of the social anxiety construct. Thus, differences in the two measures’ classification correspondence have been observed (Epkins, 2002; Morris & Masia, 1998). Morris and Masia found that only 54% of children (fourth through sixth grade) identified by one measure as being above the cutoff were so identified by both measures. Epkins similarly found in her community sample that only 43% of those identified as high on the SPAI–C were also high on the SASC–R, but 80% of those identified as high on the SASC–R were also high on the SPAI–C. InderbitzenNolan, Davies, and McKeon (2004) obtained similar results using an older adolescent (13 to 17 years) school sample in that 63% of those who scored high on the SPAI–C also scored high on the SAS–A; 77% of those scoring high on the SAS–A also scored high on the SPAI–C. Taken together, these studies’ findings indicate that the two scales do not assess the identical construct of social anxiety. Thus, if the purpose for using a self-rating scale of social anxiety is for identifying those adolescents who most likely meet DSM–IV diagnostic criteria for SOP, the current research evidence suggests that the SPAI–C is likely to be a better selection instrument than the SAS–A. Given that these studies’ findings also show that some adolescents who meet for SOP would be missed if only the SPAI–C was used, an evidence-based assessment approach would suggest the need to rely on another assessment method (e.g., an interview schedule; Inderbitzen-Nolan et al., 2004). On the other hand, if one was more interested in learning about adolescents’ fears of negative evaluation, the SAS–A is the better choice. Another avenue that needs to be pursued in the screening area relates to determining the symptoms that are most essential to a given anxiety diagnosis and thus should be assessed first (as screeners) prior to assessing all the symptoms that comprise a given anxiety disorder diagnosis. A couple of such studies have been conducted in the GAD area. Tracey, Chorpita, Douban, and Barlow (1997), for example, found that the symptom of restlessness/keyed up, when endorsed by youths (ages 7 to 17 years), was predictive of youths receiving a DSM–IV GAD diagnosis. The symptom of irritability, when endorsed by parents, also was predictive of youths receiving a DSM–IV GAD diagnosis. The extent that these symptoms have specificity for GAD, however, was not investigated (e.g., is irritability similarly predictive of major depressive disorder?). 401 SILVERMAN AND OLLENDICK In a subsequent study, Pina, Silverman, Alfano, and Saavedra (2002) evaluated not only the symptoms comprising the uncontrollable excessive worry criteria of DSM–IV GAD, but also the physiological symptoms criteria, with separate evaluations conducted for children (N = 57; ages 6 to 11 years) and adolescents ages (N = 54; ages 12 to 17 years). More specifically, the diagnostic value of each symptom, operationalized by the odds ratio—an index that takes into account the symptom’s sensitivity, specificity, positive predictive power, and negative predictive power—was determined. Results indicated that uncontrollable excessive worry in the area of “health of self” (as reported by children and adolescents and parents of adolescents) had the highest diagnostic value (i.e., the highest odds ratio) relative to the average of all the other symptoms comprising the uncontrollable excessive worry criteria of DSM–IV GAD. In other words, this symptom came up as highly specific or descriptive of GAD; thus when endorsed as Yes, youths ended up with a GAD diagnosis most of the time, and when endorsed No, youths did not end up with the diagnosis most of the time. Similarly, uncontrollable excessive worry in the area of “health of others” (as reported by parents of children) had the highest diagnostic value for GAD relative to the average value of the other areas of uncontrollable excessive worry. The physiological symptoms associated with uncontrollable excessive worry with the highest diagnostic value were irritability, trouble sleeping (as reported by children), can’t sit still and relax, can’t concentrate (as reported by adolescents), can’t concentrate (as reported by parents of children), and can’t sit still and relax and trouble sleeping (as reported by parents of adolescents). If the findings of Tracey et al. (1997) and Pina et al. (2002) are replicated, they would suggest a sequence for inquiring about GAD symptoms (i.e., start with the symptoms indicated previously as having highest diagnostic value, followed by those with average, and then those with lower than average value). Diagnostic efficiency research has not been conducted for other anxiety disorders, except for posttraumatic stress (Lonigan, Anthony, & Shannon, 1998). In terms of screening for anxiety disorders in children and adolescents, the available self-rating scales are likely to select more false positives than true positives (Costello & Angold, 1988). In other words, youths identified as anxious at an initial screening are likely not to be so identified the next time. In the study cited previously by Mattison et al. (1988) using the RCMAS, the sensitivity rates were found to be 41%, 36%, and 48%, depending on the cutoff technique employed. Using the STAIC, Hodges (1990) found the scale to have a sensitivity of 42% and a specificity of 79% in inpatient children. 402 A potentially useful approach for developing empirically based screening methods is to use receiver operator characteristic curves. Studies that rely on receiver operator characteristic curves focus on the area under the curve (AUC) to estimate diagnostic accuracy across the range of scores on individual scales. This approach is not dependent on prevalence (as is positive predictive value) or on the cutoff scores (as are sensitivity and specificity; Rey, Morris-Yates, & Stanislaw, 1992). In general, AUC may be evaluated according to the guidelines of Swets and Pickett (1982): .50 to .70 (low accuracy), .70 to .90 (moderate accuracy), and greater than .90 (high accuracy). The only study we could locate that used receiver operator characteristic curves in the youth anxiety area is Dierker et al. (2001). In this study, two anxiety self-rating scales (RCMAS and MASC) and one depression self-rating scale (Center for Epidemiologic Studies Depression Scale) were evaluated with respect to each of their respective levels of diagnostic and discriminative accuracy for detecting anxiety and depressive disorders in a school-based survey of ninthgrade children. Youths scoring at or above the 80th percentile on one or more of the three rating scales and a random sample scoring below this threshold participated in follow-up ADIS–C interviews within 2 months of the screening sessions. Results indicated that MASC scores were partially successful in identifying certain anxiety disorders, but only among girls. Specifically, among girls, only GAD was significantly associated with the MASC composite scale; thus neither SOP nor specific phobia was significantly associated with the MASC composite scale. Interestingly, among boys, the externalizing disorders were found to show a marginally significant association with the MASC composite scale. The RCMAS was found to be the least successful in identifying anxiety and depression. Moreover, only the MASC scale was found to have moderate predictive power for anxiety comorbidities. Specifically, the MASC composite scale had moderate predictive power for both boys and girls with social or specific phobia (AUC boys = .73, girls = .73) and for girls with SOP or GAD (AUC = .80). Interestingly, both the RCMAS and the Center for Epidemiologic Studies Depression Scale showed moderate accuracy only for predicting an externalizing disorder among boys. Thus, the Dierker et al. (2001) findings suggest that the MASC holds more promise than the RCMAS as a screen, but this is only in terms of screening for GAD in girls and anxiety comorbidities. That the MASC composite scale was marginally associated with screening boys with externalizing disorders also requires further study. Nevertheless, the Dierker et al. study does, in our view, represent a good launching pad for continued evaluative work on the MASC as a potential screen for anxiety disorders. EVIDENCE-BASED ASSESSMENT OF ANXIETY Handling Multiple Informants’ Reports in the Assessment of Anxiety Paralleling the general findings in the parent–youth (dis)agreement research literature (e.g., Achenbach et al., 1987), research findings in the anxiety area show high parent–youth discordance. An earlier review by Klein (1991) revealed high discordance in the dimensional assessment of a youth’s level of anxiety in that parents and youths display low correspondence in their scores on rating scales. High parent–youth discordance also has been found in the categorical assessment of youth anxiety using interview schedules. Here we briefly summarize the categorical assessment research findings given that this work is relatively recent. In a four-community epidemiology survey of 9- to 17year-old youths and their parents (1,285 pairs; 247 of the dyads were interviewed) using the Diagnostic Interview Schedule for Children (Version 2.3), P. S. Jensen (1999) examined parent–youth agreement along a variety of disorders, including anxiety. Of interest was the finding that although parents and youths rarely agreed on the presence of diagnostic conditions, regardless of diagnostic types, for ADHD, oppositional defiant disorder, and depressive disorder, parents and youths were similar in that they excessively identified these disorders. In contrast, within the overall category of anxiety disorders, differences were found between parents and youths regarding which disorders they were most likely to identify, with some disorders (and symptoms) being excessively reported by one source but not necessarily by the other source, and vice versa. SAD, for example, has many overt signs (e.g., clinging, refusal to attend school) that were reported as highly distressing to some mothers but not necessarily distressing to these mothers’ children. Conversely, mothers who suffered from their own feelings of separation distress when separated from their children did not acknowledge the SAD as part of their child’s clinical picture, but the children did. Evidence for discrepant reports between parents and youths has been reported recently using the ADIS: C/P (Choudhury, Pimentel, & Kendall, 2003; Grills & Ollendick, 2003; Rapee et al., 1994). Choudhury et al., for example, reported that in 45 children (ages 7 to 14 years) and parents who presented to a child anxiety disorders specialty clinic, levels of agreement were low for all the major anxiety disorders. This was true for both the primary or principal diagnosis as well as for whether the anxiety diagnosis was determined to be present anywhere in the child’s clinical picture. Grills and Ollendick reported similar findings in a nonspecialty research clinic. Specifically, 165 children and adolescents (ages 7 to 16 years) and their parents were separately interviewed with the ADIS: C/P. Parent–youth agreement was low and fell below chance occurrence (50%) for all disorders, but especially so for the anxiety (range between 24% and 32%) and depressive disorders (8%). Youth characteristics such as age, gender, and social desirability were not related systematically to these disagreements, nor were family variables such as conflict in the family or parental psychopathology. Clinicians tended to agree more with the reports of parents. Using 98 children and young adolescents (ages 7 to 14 years) referred to a childhood anxiety specialty clinic and who met diagnostic criteria for SAD, SOP, or GAD, Comer and Kendall (2004) found that although there was high parent–youth discordance at the diagnostic level, it was not as high (i.e., there was stronger agreement) at the symptom level. Parent–youth agreement was stronger for observable than unobservable symptoms and weaker for schoolbased than nonschool-based symptoms. Krain and Kendall (2000) examined the influence of mother and father anxiety and mother and father depression on each of their respective ratings of their child’s anxiety levels. Agreement between mother and father ratings of child anxiety also was examined. Participants consisted of 239 youths (ages 7.5 to 15 years old) and their parents (193 fathers, 238 mothers) from a childhood anxiety specialty clinic. Results indicated that both mothers and fathers rated their children as significantly more anxious than the children rated themselves, but mothers rated their children as more anxious than did fathers. Both mother and father ratings of child anxiety were higher for older than for younger children. In addition, although significant correlations were found between mother and child ratings of anxiety for the total sample, younger children, boys, and girls, significant correlations only were found between fathers’ and boys’ ratings. In terms of parents’ self-ratings of anxiety and depression, mothers’ selfratings of depression predicted mothers’ ratings of child anxiety for the total sample, older children, and girls. Fathers’ self-ratings of depression predicted fathers’ ratings of child anxiety only for girls. Overall, the Krain and Kendall study is an important first step in examining agreement between mothers’ and fathers’ ratings of their child’s anxiety. Further research is needed on the factors that influence the different patterns of findings obtained with mothers and fathers. Research findings are mixed on the influence of age in parent–youth (dis)agreement as well as on the reliability of parent and youth reports about youth anxiety. Rapee et al. (1994) found no difference in parent–youth agreement based on age, but there was significantly greater agreement between parents and youths for diagnoses of SOP based on increasing age. Choudhury et al. (2003) and Grills and Ollendick (2003) similarly found no difference in parent–youth agreement based on age. With regard to reliability, Edelbrock (1985) found parent reports of internalizing symptoms were more reliable than younger children’s 403 SILVERMAN AND OLLENDICK (ages 6 to 9 years) self-reports. For older children (10 years and above), Edelbrock found children’s self-reports of their own internalizing symptoms were more reliable than parents’ reports. Silverman and Eisen (1992) did not find age differences in parent and youth reliability reports about youth anxiety. Foley et al. (2005) recently noted reasons for low parent–youth anxiety agreement in community-based interview studies, including (a) a “hierarchy of informant knowledge” in that the sources may agree that a child is anxious but may disagree on number of symptoms or on whether the anxiety was best attributed to a generalized source of worries or to specific phobic triggers; (b) misinterpretation of diagnostic status in that symptoms of anxiety are taken as symptoms of another disorder, such as depression; (c) differential thresholds, standards, or time frames for identifying a deviation from normal functioning; and (d) variable maternal rating bias or maternal sensitivity. In summary, mothers, fathers, and youths provide useful and complementary information that relates to meaningful, clinically credible diagnosis. However, high disagreement, particularly at the diagnostic level, for nonobservable symptoms and for schoolbased symptoms exists. Generally, both parent-only and youth-only derived diagnoses are accompanied by substantial specific impairment as well as overall impairment. The influence of youth’s age on parent–(dis)agreement is uncertain as well. The influence that parental psychopathology, including anxiety and depression, plays in leading to discrepancies also is uncertain and may be different for mothers and fathers. In light of these findings, the general consensus in the youth assessment area (P. S. Jensen, 1999), including anxiety (Comer & Kendall, 2004), is that mothers and children—and fathers if possible—should be considered in assessing youth symptoms and diagnoses. One is not necessarily more right or wrong than the other(s). By carefully considering each source’s information, there is increased likelihood that no child or adolescent is denied services (Comer & Kendall, 2004; Foley et al., 2005). De Los Reyes and Kazdin (in press), in a comprehensive review of the informant discrepancy literature in clinical child and adolescent psychology, further proposed that in addition to obtaining information of youths’ problems from multiple informants, efforts should be made to collect information from these informants about their perceptions of why the youth is exhibiting these problems, as well as their perceptions of the youth’s treatment. De Los Reyes and Kazdin further discussed how gathering this type of information can serve as the basis for an assessment model that can guide research and clinical practice to help understand informant discrepancies in clinical child and adolescent research. 404 Conclusions and Recommendations Based on our review of the literature, it is obvious that much has been accomplished on the journey to establish evidence-based assessments for anxiety and its disorders in childhood and adolescence. Promising structured and semistructured diagnostic interviews, self-rating scales, direct behavioral observation systems, and self-monitoring forms have all been pioneered in recent years. Yet, it is equally obvious that much remains to be accomplished in the years ahead. We believe the review of the literature does allow us to make tentative evidence-based recommendations for use in assessing anxiety and its disorders in children and adolescents. Our recommendations are framed around the main purposes and goals of assessment as well as around the additional issues we covered in this article. We emphasize that the recommendations are tentative, as considerable more research is needed in all of these areas before we can truly say we have an “evidence-built house.” Indeed, we wrestled with whether we even should attempt to provide recommendations. The reason for our uncertainty was because we were unsure how much evidence is needed to declare that a given assessment method is evidence based for attaining a specific assessment goal. At this point, a set of criteria or guidelines for what is an evidence-based assessment is simply not there. For example, how many studies, done by how many different investigators, using how many different types of samples does one need to declare: This is an evidence-based method for accomplishing Goal X? We hope this special section will serve as a catalyst toward developing guidelines for an evidence-based assessment. We also hope that researchers and clinicians will have a pragmatic attitude toward the assessment process of clinical child and adolescent problems, including anxiety, in terms of being open to new methods, new instruments, and new ways of doing things, as further research evidence becomes available regarding what works best. In the meantime, we delineate a tentative set of evidence-based recommendations for assessing anxiety and its disorders in children and adolescents. Tentative Evidence-Based Recommendations 1. To screen for anxiety disorders, rating scales have been most frequently used. In comparing the use of the RCMAS or the MASC, the MASC has stronger evidence and so we therefore recommend this measure. The evidence is limited, however, to screening for GAD in girls and anxiety comorbidities in girls and boys (i.e., specific phobia and SOP). Until more evidence becomes available, we recommend that screening for anxiety disorders not rely simply on the MASC EVIDENCE-BASED ASSESSMENT OF ANXIETY but be accompanied by another assessment method, such as a diagnostic interview schedule. 2. To screen for SOP, the evidence suggests using the SPAI–C. However, as with the MASC, we recommend not relying simply on the SPAI–C but to use another assessment method as well. To assess youths’ fears of negative evaluation, the SAS–A is the better choice. Overall, we recommend that one does not assume that scales designed to assess similar constructs will identify the same group of youths. 3. There is some preliminary evidence of potential screening items for GAD. However, this work requires further replication and extension with other disorders and samples. 4. To discriminate among youths with anxiety disorders and other disorders, the SCARED and MASC currently have the most support. The FSSC–R, both parent and child versions, has evidence of being able to discriminate between cases of SOP, simple or specific phobia of the dark or sleeping alone, animals, or shots or doctors. In general, we recommend that scales’ factor scale scores be examined, not just total scores, when trying to discriminate youths with anxiety disorders and other disorders. This is because different findings have emerged depending on whether total or factor scale scores are used (e.g., RCMAS and CASI). The Worry/Oversensitivity factor scale appears able to discriminate best relative to the Total scale and the other two RCMAS factor scales. 5. To discriminate between anxiety and depression, we recommend using scales specifically designed for this purpose, such as the Revised Child Anxiety and Depression Scale. Be aware that the different tripartite-based self-rating scales are not equivalent, and each appears to capture differential aspects of the tripartite model. 6. To diagnose anxiety disorders in children and adolescents, structured or semistructured clinical interviews lead to more reliable anxiety diagnoses than unstructured clinical interviews. The interview schedule that has been used most frequently in the youth anxiety area has been the ADIS: C/P. In research-based clinics, the reliability and validity of anxiety diagnoses have been documented using the ADIS: C/P. Further information about reliability when the interview is used in community clinics and when diagnosing disorders of varying base rates is needed. Also needed is a test of the interview schedule’s treatment utility. On a clinical level, however, it appears to us that having reliable and valid anxiety diagnoses pave the way for successful implementation of exposure-based CBT. 7. To identify and quantify anxious symptoms and behaviors, interview schedules and rating scales have been used most frequently in research, and we recommend these assessment methods for this purpose. Caution is needed in interpreting scores using these assessment methods, however, because scores obtained on them are on an arbitrary metric, and their linkage to meaningful or real-life events is lacking. Although one might expect direct behavior observations would be particularly useful in identifying and quantifying anxious symptoms or behaviors, there is actually only limited research, and basic psychometric information such as retest reliability is lacking. For now, we primarily recommend direct behavioral observations for clinical formulation purposes (e.g., to obtain conceptually interesting information that might help in better understanding how the child or adolescent reacts when faced with the feared object of event, how the parents interact with their child in certain situations). 8. To identify and quantify controlling or maintaining variables of anxiety, we recommend the use of rating scales, direct observations, and self-monitoring procedures. The limits noted under Number 6, however, regarding the arbitrary metrics of rating scales, hold here as well. In addition, although direct observations and self-monitoring methods likely have clinical utility, concerns exist regarding their feasibility, retest reliability, and incremental validity. 9. To evaluate treatment outcome, diagnostic recovery rates using the ADIS interviews, the RCMAS, and the CBCL have been the most widely used, and they all have been found to be sensitive to change. If investigators opt to include some of the newer measures (e.g., the MASC) or a specific anxiety measure (e.g., the SPAI–C) or a measure of a related construct (e.g., the FSSC–R), we still recommend the continued use of the previously mentioned three measures. In this way, the field can begin to have a set of standard measures that will allow for improved cross-study comparisons. It also will be a way to begin investigating what clinically significant change truly means on each of these scales as the data accumulate across different studies. 10. Any of the assessment methods can be used to evaluate moderators and mediators of treatment, but ratings scales would appear to be the easiest and most efficient way to do so. Research in this area is scarce, and we recommend that more be done in this area following the guidelines of Kazdin and Nock (2003) and Weersing and Weisz (2002). 11. We recommend careful consideration of multiple sources of information, particularly mother, father, and child. Do not assume there is a gold standard, as different perspectives likely reflect biases and varying perceptions of what is in the best interest of the child or adolescent. Further work on understanding the meaning of these discrepancies is needed. 12. We recommend not only multi-informant assessment but also multiresponse assessment, given that research findings in the anxiety disorders area show high discordance among the tripartite features of anxiety. 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